Sudden death due to acute variceal bleeding: A review of diagnostic challenges and clinical presentation

Abstract

Acute variceal bleeding is one of the most fatal complications in patients with pre-existing portal hypertension secondary to chronic liver disease. Fatality from this condition is potentially preventable but requires urgent medical attention. The diagnosis is often challenging because patients may present with diverse manifestations, ranging from vague epigastric discomfort to haematemesis, melaena, syncope, haemorrhagic shock, or sudden cardiovascular collapse. In some cases, fatal haemorrhage may occur before a definitive diagnosis is established or therapeutic intervention can be initiated, making sudden death the first clinical manifestation. In the emergency setting, upper gastrointestinal endoscopy remains the diagnostic gold standard; however, its utility may be limited in rapidly deteriorating or out-of-hospital patients. This review summarises the current evidence on the pathophysiology of variceal rupture, emergency clinical presentation, diagnostic pitfalls, and factors associated with sudden death. It also highlights the importance of early recognition, prompt risk stratification, and timely intervention to reduce mortality, while emphasising the role of clinicopathological correlation in patients presenting with fatal or unexplained upper gastrointestinal haemorrhage.

Keywords: Acute variceal bleeding; Sudden death; Esophageal varices; Portal hypertension; Postmortem examination; Forensic pathology; Gastrointestinal hemorrhage

Core Tip: Sudden death due to acute variceal bleeding is an uncommon but potentially fatal complication of portal hypertension that may occur without a previously diagnosed liver disease. The diagnosis can be particularly challenging in out-of-hospital deaths, where clinical information and endoscopic confirmation are unavailable. This review highlights the varied clinical presentations, mechanisms of catastrophic haemorrhage, and important diagnostic pitfalls. Careful scene investigation, systematic autopsy examination, histopathology, and clinicopathological correlation are essential for establishing the cause of death and excluding alternative sources of gastrointestinal haemorrhage. Greater awareness among clinicians and forensic pathologists may improve diagnostic accuracy and cause-of-death certification.