Background: Elderly abuse is a prevalent entity in the Indian society. Apart from physical and verbal abuse, neglect is very commonly seen in families with disputes. Neglect as a form of elderly abuse rarely comes to light as many people are not forthcoming to disclose these aspects due to social stigma associated with it.Case Report: Here is a case of an elderly male who committed suicide to end his misery of unresolving dysphagia as stated in his death note.Conclusion: An oesophageal leiomyoma was incidental finding at autopsy which explained the symptoms mentioned in his death note which drove him to desperation to end his life

Mathias, M

Shetty, M

Shetty, S S

Suares, Sh

English

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International Journal of Medical Toxicology and Forensic Medicine. 2016;6(2): 112-5.  Oesophageal Leiomyoma: an Incidental Autopsy Finding in a Neglected Elderly Individual Suares Sh1, S-Shetty S1*, Mathias M2, Shetty M1 1 Department of Forensic Medicine and Toxicology, K.S Hegde Medical Academy, NITTE University, Mangalore, India 2 Department of Pathology, K.S Hegde Medical Academy, NITTE University, Mangalore, India   A R T I C L E I N F O  A B S T R A C T  Article Type: Case Report   Article History: Received: 5 Dec 2015 Revised:  -  Accepted: 9 Dec 2015   Keywords: Elder Abuse Oesophageal Leiomyoma Autopsy   Background: Elderly abuse is a prevalent entity in the Indian society. Apart from physical and verbal abuse, neglect is very commonly seen in families with disputes. Neglect as a form of elderly abuse rarely comes to light as many people are not forthcoming to disclose these aspects due to social stigma associated with it. Case Report: Here is a case of an elderly male who committed suicide to end his misery of unresolving dysphagia as stated in his death note. Conclusion: An oesophageal leiomyoma was incidental finding at autopsy which explained the symptoms mentioned in his death note which drove him to desperation to end his life.   Copyright©2016 Forensic Medicine and Toxicology Department.  All rights reserved. Implication for health policy/practice/research/medical education: Oesophageal leiomyoma     Please cite this paper as: Suares Sh, Shetty S, Mathias M, Shetty M. Oesophageal leiomyoma: an Incidental Autopsy Finding in a Neglected Elderly Individual. International Journal of Medical Toxicology and Forensic Medicine. 2016; 6(2): 112-5.   1. Introduction:*  Elderly abuse is a well-hidden form of domestic abuse that exists in the Indian society. It rarely comes to light as people are not very forthcoming to discuss issues about the family for the fear of tainting the family name or reprimand from the caretakers at home. World Health Organisation defines elderly abuse as a single or repeated act or lack of appropriate action occurring within any relationship where there is an                                                           Corresponding author: Shetty S, MD. Assistant Professor, Department of Forensic Medicine and Toxicology, K.S Hegde Medical Academy, NITTE University, Mangalore, India E-mail: drsurajshettyfmt@gmail.com expectation of trust, which causes harm or distress to an older person (1).         The detection of elder abuse is still in its stages of infancy after it found its first mention as “Granny battering” in 1975 (2-3). Although the literature on elder abuse is sparse, it shows a world-wide distribution (3).                                                                              Neglect (active and passive), physical, psychological, sexual and financial abuse fall under the ambit of elderly abuse (4).  Fox AW (3) elaborated in his review article that the first four forms of abuse are likely to be encountered by a health care personnel. Elder abuse may present to General practitioners, Physicians, Psychiatrists, Psychologists, Emergency Medicine, Orthopaedicians, Forensic pathologists, Physiotherapists, nurses and Health workers Oesophageal leiomyoma: an Incidental Autopsy Finding in a Neglected Elderly …              Suares Sh et al International Journal of Medical Toxicology and Forensic Medicine. 2016;6(2)                                    113 (3). Thus, the people in the medical field have the responsibility of being more vigilant to identify such cases, study the various factors that precipitate abuse and strengthen the databases regarding the same. This would help in formulating programmes and strategies in the form of schemes and laws to protect the rights of the elder people. This article explores the case of an elderly male whose family neglected his medical needs which finally drove him into committing suicide by consuming poison.   2. Case Report: A 62-year old male who consumed organophosphorus pesticide to commit suicide, died despite being treated at a tertiary care centre. During psychological autopsy, history of reduced appetite and loss of weight in the last few months was elicited. He was also stated alcohol consumption and withdrawn during the period. At autopsy, a well circumscribed oesophageal mass measuring 4cm×3.5cm× 4cm was found in the posterior wall of the oesophagus in its middle one third (Figure 1 and Figure 2). The rest of the oesophageal wall was normal. No other tumours were found in the gastro intestinal tract. The segment of oesophagus with the mass was sent for histopathological examination.  After autopsy, the family was further questioned about the medical ailments of the deceased after which they gave a history that the man complained of dysphagia since the past three months. The family neglected his complaints and thus no treatment was sought. Details of histopathological examination are as follows: Gross findings: segment of oesophagus with a mucosal aspect showing a pale white firm mass measuring 4cm×3.5cm lying at a distance of 9cm from the gastric margin. Cut surface was pale white with whorled appearance. Mucosa appeared normal without ulceration. Microscopy findings: the mass showed spindle cells arranged in whorls and fascicles. No mitotic figures were seen.  Histopathological examination of the tumour showed features of leiomyoma with hyaline changes (Figure 3). 3. Discussion: The first report of elder abuse came to light in 1975 in the United Kingdom and was termed as granny battering (2). Gradually this form of abuse was recognised worldwide as more cases came to light. Various studies have concluded that elder maltreatment is under reported and under diagnosed form of domestic abuse. The victims usually try to conceal this as it would harm the family dignity or for the fear of rebuke from the perpetrator, who is usually a close family member (4-7). Neglect is the refusal to assist the elderly person with needed personal care or to  Fig. 1.  It is showing oesophageal mass at autopsy.  Fig. 2.  Oesophageal mass on cutting open.  Fig. 3.  Histopathology showing spindle cells with cigar shaped nuclei arranged predominantly in fascicles. Suares Sh et al              Oesophageal leiomyoma: an Incidental Autopsy Finding in a Neglected Elderly … 114                                     International Journal of Medical Toxicology and Forensic Medicine. 2016;6(2) provide them with necessary access to food, clothing and medical treatment (8).  The present case differs from the other case reports as there was an established cause of death due to organophosphorus insecticide poisoning, elderly abuse in the form of neglect of  medical needs by the family was identified as the driving force for deliberate self-harm. The patients with oesophageal leiomyoma are known to present with a spectrum of symptoms from epigastric pain, dysphagia, food sticking to throat or chest, retrosternal pain, dyspnoea, hiccups to pleuritic chest pains (9-11).  In the present case, the patient complained of dysphagia. The imaging modalities for the detection of the tumour include Barium Swallow (filling defect), Endoscopic Trans Oesophageal Ultrasonography to know the plane of the tumor and CT scan of the chest for assessing extra oesophageal extent (11, 12). Enucleation via endoscopic, open or thoracoscopic methods and oesophageal resection and reconstruction is the main modality of treatment. Most patients make an uneventful recovery (9). In the present case, the patient complained of dysphagia. However, his medical needs were neglected and no investigations were conducted. Thus the condition remained undiagnosed and untreated. Studies conducted in India showed that 11% of the elderly have experienced some form of abuse after turning 60 years old (13). The study elaborates that 4.2% experienced abuse in the form of neglect (13). The sons and daughters – in – laws were the offenders in 60% of elderly abuse cases (13). Similar results were observed in a study done by Chokkanathan et al in one of the metropolitan cities of the country (14). The present case, the elderly male was neglected by his spouse and son, who were staying with him. Elderly abuse is a complex entity with numerous causal factors that differ from one society to the other. The following risk factors were identified in the Indian society with reference to the present case which left the older individual susceptible to abuse. Shared living situation with proximity is one of the major causes of abuse. It gives opportunities of contact with increased conflicts thus increasing the chances of abuse. The patriarchal Indian society mandates that the sons will be the care providers for the parents. The caregivers often shoulder the burden of meeting the financial needs of the dependent elder individual which leads to frustration. Thus, there are greater chances of abuse by the son and daughter in law (7, 13). In the present case, the deceased was staying with his spouse and children and was financially dependent on his sons. He would use the money for alcohol which might have been the cause of the family not paying heed to his health ailments. Social isolation is recognised as another risk factor for elder abuse as the victim is isolated forms his friends and other relatives (7, 8). It leaves very little scope for intervention to bring about any changes in the environment that the elderly lives in. In the present case, the deceased was isolated from the other family members as he would get abusive after alcohol consumption.    It is also noted that abusive parents end up being victims of elderly abuse by their children. Thus a disharmonious parent child relationship usually leads to children harnessing a feeling of resentment for the parent and is later manifested as different forms of elderly abuse (6). The present case, the spouse and son stated that he was violent and abusive in his younger days and had neglected his family due to alcohol addiction.  Thus, abuse against the elderly has been recognised as an important challenge to the elderly health in India. The present case substantiates that elderly abuse is a rampant and prevalent evil in the Indian society.  4. Conclusion: This case highlights the prevalence of elderly abuse in the form of neglect in the Indian society. A timely medical consultation would have helped in diagnosing a benign and easily respectable tumour thus preventing the loss of a life. The forensic pathologist should not restrict his domain by merely looking into the cause of Oesophageal leiomyoma: an Incidental Autopsy Finding in a Neglected Elderly …              Suares Sh et al International Journal of Medical Toxicology and Forensic Medicine. 2016;6(2)                                    115 death. In the present case a deeper understanding of the complexities of the case and examination of the contextual variables aided in unearthing neglect of the elderly to be the precipitating factor for suicide. Thus, the present case report emphasizes the need of developing protocols and questionnaires relevant to various specialities that come in contact with the patients to recognise such cases of elder abuse and prevent the adverse outcomes.  5. References: 1. WHO. The Toronto declaration on the global prevention of elder abuse. Geneva: WHO, 2002. 2. Burston GR. Letter: Granny-battering. Br Med J. 1975;3(5983):592. 3. Fox AW. Elder abuse. Med Sci Law. 2012;52(3):128-136. 4. Loughlin AO. Abuse, Neglect and Mistreatment of Older People: An Exploratory Study [Internet]. Report No.: 52. Available from: http://www.ncaop.ie/publications/research/reports/52_ABUSE.pdf  5. PhD J, PhD J, Turner M. Elderly in America: A Descriptive Study of Elder Abuse Examining National Incident-Based Reporting System (NIBRS) Data, 2000–2005. J Elder Abuse Negl. 2009;21(4):325–45. 6. Homer AC, Gilleard C. Abuse of elderly people by their carers. BMJ. 1990;301(6765):1359–62. 7. Lachs MS, Pillemer K. Elder abuse. The Lancet. 2004;364(9441):1263–72. 8. Cheryl Mildenberger and Henry C Wessman. Abuse and Neglect of Elderly Persons by Family Members: A Special Communication. PHYS THER. 66:537–9. 9. Zielinski J, Kruszewski WJ, Jaworski R, Haponiuk I, Irga N, Zygon J, et al. Rare oesophageal tumours: experience of one centre. Eur Surg. 2012;44(6):361–5.   10. Hickling P, Buksh K, Beck P. A case of leiomyoma of the oesophagus complicated by superior vena cava obstruction and associated eosinophilia. Postgrad Med J. 1980;56(656):431–4. 11. Standerfer RJ, Paneth M. Recurrent leiomyoma of the oesphagus. Thorax. 1982;37(6):478–9. 12. Mendis D, Molony N. “Coughing up a tonsil” - oesophageal leiomyoma. J Surg Case Rep. 2012;2012(1):3.   13. Skirbekk V, James K. Abuse against elderly in India – The role of education. BMC Public Health. 2014;14(1):336.  14. Chokkanathan S, Lee AEY. Elder mistreatment in urban India: a community based study. J Elder Abuse Negl. 2005;17(2):45–61.   

Oesophageal Leiomyoma: an Incidental Autopsy Finding in a Neglected Elderly Individual

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Oesophageal Leiomyoma: an Incidental Autopsy Finding in a Neglected Elderly Individual

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