Most probable immediate cause of death: Septic shock with multiple organ dysfunction syndrome (MODS).

Metabolic encephalopathy is generally a manifestation of severe sepsis and organ failure, not the primary cause of death.

A clinically appropriate causal sequence, if a postoperative intra-abdominal source was suspected or documented, would be:

Do not state a specific operative complication, such as bile leak or bowel injury, unless it was actually established. If no source was identified, word it as “sepsis of presumed postoperative intra-abdominal origin.”

For death certification, “cardiorespiratory arrest,” “MODS,” and “metabolic encephalopathy” alone should not be used as the underlying cause. The certificate should show the disease sequence that initiated the fatal event, consistent with CDC death-certification guidance. Sepsis is life-threatening organ dysfunction from infection, as defined by the CDC sepsis guidance.