A 57-year-old woman, under medication for depression and high blood pressure, was found dead at home. Four days earlier, she had consulted an emergency department for non-specific abdominal pain and started treatment with anti-inflammatory drugs.
Autopsy findings: apart from obesity (BMI 34.9 kg/m2), the only significant finding was that the gallbladder was markedly distended and enlarged, containing a large gallstone (4.5 x 2.5 cm) impacted in the gallbladder neck. The gallbladder wall was thickened and the mucosa hyperemic with focal haemorrhage. No purulent exudate, perforation, abscess, fistula or peritonitis was observed. The cystic and common bile ducts were patent. Toxicological analysis detected benzodiazepines, mianserin, ibuprofen and ketoprofen at therapeutic concentrations.
Microscopic findings: numerous positive biliary emboli were identified in the small bile arteries, arterioles and alveolar capillaries of the lungs by Hall's technique. Biliary emboli were also identified in the liver (sinusoids and portal veins), in the gallbladder mucosa and in the spleen. Other microscopic findings of interest were the presence of numerous fibrin thrombi in the arterioles and alveolar capillaries of the lungs and in branches of the portal vein and in hepatic sinusoids; focal necrosis of hepatocytes, leukocytosis in the hepatic sinusoids and in the small blood vessels of the lung; as well as the occasional presence of cholesterol emboli in the lungs. The gall bladder showed gangrenous cholecystitis. Bile aggregates and cholesterol crystals were observed adhering to its mucosa.

In view of these findings, biliary embolism in association with disseminated intravascular coagulation and probable sepsis was established as the cause of death.

