An 85-year old lady presented as an emergency with sudden onset of severe left sided abdominal pain and vomiting for two days. This was associated with constipation for 3 days. She had a past medical history of atrial fibrillation, angina, and pulmonary embolism for which she was anticoagulated with warfarin. There was no history of trauma.\nOn examination she was haemodynamically stable. Her abdomen was generally tender, maximal tenderness being in the left hypochondrium and left lumbar region, associated with some guarding and rigidity. Bowel sounds were present and the rectal examination was unremarkable.\nThe blood tests revealed normal haemoglobin, marginally raised white cell count (12.5) and C- reactive protein (25.3), and a grossly deranged International Normalised Ratio (INR) of 8.9. Her renal and liver functions function tests were within normal limits. An erect Chest X-ray and supine abdominal films were both unremarkable. Computed Tomography (CT) Scan showed a long abnormal loop of thick walled jejunum with a small amount of free fluid in the intraperitoneal cavity (Figure and ).\nA diagnosis of spontaneous intramural haematoma of the jejunum was made. She was treated conservatively with nil by mouth, intravenous fluids, and nasogastric suction. Fresh frozen plasma and vitamin K were given to normalise her clotting parameters. Her symptoms subsided gradually over the next couple of days and she was gradually started on fluid and diet. The clotting parameters normalized and she was discharged home on normal diet six days later.
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.