Activated charcoal in the stomach: Clinical familiarity and limited gross recognition

Activated charcoal is widely used in the medical management of acute intoxications, yet its gross appearance at autopsy is poorly described and may represent a diagnostic pitfall. We report a case highlighting this issue. An elderly man with a history of cardiovascular disease, diabetes mellitus, and prostate cancer was found unresponsive in his closed residential garage after making suicidal statements. Open bottles of amlodipine and glimepiride were found on his person. He was hospitalized, where routine toxicology screening was negative, and he died in the intensive care unit less than 24 h after admission. At autopsy, the stomach contained an abundant amount of dense, black, odorless, thick material adherent to the gastric mucosa which wiped off after gentle cleaning. After removal, the underlying mucosa was intact, without hemorrhage or ulceration. Review of medical records indicated that activated charcoal had been administered during hospitalization due to concern for intentional medication ingestion. Subsequent expanded toxicology testing demonstrated a markedly elevated amlodipine concentration, consistent with acute toxicity. The cause of death was certified as amlodipine toxicity, and the manner of death as suicide. This case illustrates the characteristic gross appearance of activated charcoal in the stomach and discusses its potential to mimic other causes of black gastric contents, including gastrointestinal hemorrhage, caustic ingestion, Wischnewsky spots, hydrocarbons, black esophagus, and iron deposition. Awareness of this finding and careful correlation of gross autopsy findings with medical history and toxicologic results are essential to avoid misinterpretation and diagnostic error in forensic practice.