Death from paraesophageal hiatus hernia: post-mortem assessment and forensic relevance

Hiatus hernias of the diaphragma are rarely recorded under forensic aspects. Their relevance is demonstrated by the case of an elderly lady who was suffering from severe abdominal pain after dinner. She vomited several times and died 4 days later. After a forgery of the notarial last will and testament was revealed, a post-mortem was performed and a paraesophageal hiatus hernia was detected. The toxicological investigation revealed high levels of pethidin, and a married couple, both of them medical doctors, responsible for the forgery of the last will was charged with murder. The pathogenetic reconstruction led to the conclusion that a mechanism of 'self-tamponing' was initiated on the grounds of a pre-existing paraesophageal hernia filled up by the last meal ingested. The blockage of the gastrointestinal passage way induced severe abdominal pain and permanent vomiting, furthermore resulting in hemorrhagic infarction and perigastritis. Death from natural cause was finally appreciated by the court and the accused were acquitted. The post-mortem estimation of paraesophageal hiatus hernias is discussed, particularly, the necessity of an in situ preparation with separate incision of the translocated part and histological investigation. A synoptic expertise of clinicians, toxicologists and forensic pathologists is mandatory for estimating the relevance of high levels of analgesics.