A 4-year-old boy was transferred to our pediatric intensive care unit from an outside hospital for further management of a persistent seizure disorder of unknown etiology. A right femoral triple lumen central venous line (CVL) had been placed prior to transfer. Five days after arrival, the patient began to exhibit increased swelling in his right lower extremity, and ultrasonography revealed a catheter-related, acute occlusive deep venous thrombosis in the right common femoral vein. He was started on LMWH (enoxaparin) at 1 mg/kg for a planned course of 3 months. Five days after initiating treatment, the CVL was removed. The patient had no personal or family history of thrombophilia or bleeding diathesis. His anti-Xa level, checked after the second dose, was within the therapeutic range.\nHis hospital course was complicated by multisystem organ failure in the setting of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome secondary to anticonvulsive therapy. One week after starting LMWH heparin, the patient experienced gross hematuria. The next day, the injection sites were noted to be slightly oozy, and, in the setting of his anti-Xa levels continuing to rise (0.87), LMWH heparin was held. He required continuous venovenous hemofiltration, during which time anticoagulation was switched to unfractionated heparin. After renal recovery, LMWH therapy was restarted at a lower dose (70% of original dose), but his anti-Xa levels continued to be labile and difficult to control. Eventually, a steady regimen was found with consistently stable and therapeutic anti-Xa levels ().\nOn the 15th day of this regimen, however, he developed signs of bowel obstruction with new onset of copious bilious vomiting. An abdominal ultrasound found a small amount of fluid in the pelvis. A CT of the abdomen and pelvis showed a high-grade small bowel obstruction, with 2 areas of small bowel, suspicious for intussusception (Figures and ). The patient's hemoglobin was found to have dropped from 9.9 to 6.2.\nHe was brought to the operating room for exploratory laparotomy. Intraoperatively, bloody ascites and multiple dilated loops of small bowel were found. Approximately 30 cm of the distal jejunum was found to be tense, heavy, firm, and discolored with a blue hue, with a hematoma that had dissected through the layers of the bowel (). A serosal defect was found on the antimesenteric border of the involved bowel, likely causing the bloody ascites. As the bowel was severely compromised, a resection of the involved segment was performed.\nPathologic analysis of the resected bowel showed an extensive, 35 cm submucosal hematoma causing internal bulging of the mucosa and submucosa, causing attenuation and focal pressure necrosis of the muscularis propria. The serosa was noted to be diffusely purple-red, with a small ovoid defect that was presumably caused by the hematoma. At both ends of the resected bowel, there was evidence of the mucosa and submucosa bulging into the lumen of the bowel as a result of the hematoma.\nThe patient recovered from the operation in the pediatric ICU with no further episodes of emesis or signs of bowel obstruction. He was restarted on LMWH 5 days later and completed his 3-month course without any further signs of bleeding. He was discharged from the hospital 3 weeks later with resolution of his seizures to a rehabilitation facility, without any further complications of bleeding or bowel obstruction.
The patient is a 52-year-old incarcerated male with a past medical history of diabetes mellitus, chronic pancreatitis, and remote history of open cholecystectomy who was transferred to the hospital for complaint of abdominal pain. He reported three days of worsening epigastric and periumbilical abdominal pain with associated nausea and obstipation. He also reported two days of hematuria without dysuria or frequency. Four days prior, he was awakened by another prisoner who was kicking him in the abdomen.\nOn presentation, he was tachycardic but normotensive. His abdomen was distended and diffusely tender. Initial lab work was notable for leukocytosis of 17 and significant coagulopathy with an unmeasurable international normalized ratio (INR), partial thromboplastin time (PTT) > 200, and prothrombin time (PT) > 120. Repeat labs confirmed the coagulopathy. He denied any ingestions or known exposures. He was given two units of fresh-frozen plasma (FFP) as well as vitamin K and his coagulopathy began to correct.\nA CT scan of the abdomen/pelvis revealed significant bowel dilatation with mural edema and thickened loops of jejunum (Figure ). There was fecalization of the proximal small bowel consistent with high-grade small bowel obstruction. Given his tachycardia, obstructive symptoms, diffuse abdominal pain and CT findings, there was concern for intestinal ischemia and the decision was made to perform an exploratory laparotomy. On inspection, the mid-small bowel was dilated with about 30 centimeters of thickened small bowel with circumferential hematoma. The entirety of the small bowel was examined and the point of obstruction appeared to be the extensive small bowel hematoma. This portion was resected and primarily anastomosed. The abdomen was closed and the patient was brought to the recovery room.\nHis post-operative labs were notable for a normalizing INR of 1.4 and PTT of 30. Given the unclear etiology for his extreme coagulopathy, Hematology was consulted. He had no family history of coagulopathies or hematologic disorders. He reported no history of bleeding symptoms prior to this episode. Coagulation studies were consistent with a deficiency of vitamin K dependent clotting factors that corrected with mixing studies. Differential diagnosis included common pathway factor deficiency, inhibitor exposure, or false result. Disseminated intravascular coagulation (DIC) and liver failure were ruled out. As his coagulopathy quickly corrected with FFP and vitamin K, the most likely etiology was exposure to overdose of a warfarin-based substance. He received additional vitamin K and recovery was otherwise unremarkable. Hematuria had resolved with correction of the coagulopathy. He was discharged on the seventh post-operative day to the prison infirmary. The final pathology was notable for portion of small intestine with transmural hemorrhage with clear resection margins.