The Pathology of Starvation: A Systematic Review of Forensic Evidence

Background: Starvation represents a specific pathological entity characterized by severe nutritional deprivation leading to multi-organ failure. Despite its forensic relevance, a comprehensive synthesis of autopsy findings remains lacking. Methods: This systematic review was conducted in accordance with PRISMA 2020 guidelines. PubMed, Scopus, and Google Scholar were searched from inception to June 2025 using a pre-specified Boolean query. Eligible studies included case reports, case series and cohort investigations reporting post-mortem evidence of starvation or starvation-related malnutrition. Data extracted encompassed demographic, contextual, macroscopic, histological, and ancillary findings. Results: Fourteen studies were included, comprising 20 individual cases and two population-based cohorts (totaling 1647 deaths). Most cases (75%) involved children, predominantly victims of domestic neglect; adults accounted for 25%, mainly due to anorexia nervosa or voluntary fasting. Six cadavers were severely decomposed or mummified. Across studies, consistent autopsy findings included extreme emaciation, near-total loss of subcutaneous and visceral fat, empty gastrointestinal tract, and diffuse organ atrophy, especially of the liver, heart, thymus, and pancreas. Histology revealed hepatic steatosis, myocardial fibrosis, thymic involution and gelatinous transformation of adipose tissue. Ancillary methods (dual-energy X-ray absorptiometry, stable isotope and anthropological analyses) confirmed malnutrition in decomposed or skeletonized remains. Conclusions: This review delineates the morphological and histopathological hallmarks of starvation and suggests the possible diagnostic value of ancillary techniques in advanced decomposition. The predominance of neglect-related pediatric cases underscores starvation as a forensic indicator of social and caregiving failure. Establishing reproducible morphological and histological indicators may improve the consistency of forensic diagnosis and strengthen the evidentiary basis for determining starvation as a cause of death.