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Case Reports
. 2018 Jun 13:2018:8780121.
doi: 10.1155/2018/8780121. eCollection 2018.

Intramural Bowel Hematoma Presenting as Small Bowel Obstruction in a Patient on Low-Molecular-Weight Heparin

Beatrix Hyemin Choi  1 , Michael Koeckert  2 , Sandra Tomita  1
Affiliations
Case Reports

Intramural Bowel Hematoma Presenting as Small Bowel Obstruction in a Patient on Low-Molecular-Weight Heparin

Beatrix Hyemin Choi et al. Case Rep Pediatr. .

Abstract

There is increasing use of low-molecular-weight heparin (LMWH) for treatment of pediatric thromboembolic disease as it has been shown to be safe and effective. It has several advantages over unfractionated heparin, such as reduced need for monitoring, easier route of administration, decreased risk of heparin-induced thrombocytopenia, and lack of drug-drug interactions. Nevertheless, LMWH still poses a bleeding risk as with any anticoagulant therapy. We present the case of a 4-year-old boy who was placed on LMWH for a catheter-related deep venous thrombosis in the setting of intractable seizures and subsequently developed a small bowel obstruction secondary to a suspected intussusception. He underwent exploratory laparotomy and was found to have an intramural bowel hematoma. Prior to this bleed, the patient had been monitored daily, and his anti-Xa levels were found to be in the therapeutic range. This case highlights the need for a high index of suspicion for spontaneous bleeding even in the setting of therapeutic anti-Xa levels.

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Figures

Figure 1
Figure 1
Anti-Xa levels of the patient throughout his hospital admission. LMWH doses are not included as they varied from day to day following the patient's lab results. For reference, the regimen used after September 7 was as follows: <0.35 units/mL: increased dose by 25%, repeat anti-Xa 4 hours after next dose. 0.35–0.49 units/mL: increased dose by 10%, repeat anti-Xa 4 hours after next dose. 0.5–0.59 units/mL: keep same dose, repeat anti-Xa next day. 0.6–1.0 units/mL: contact on call fellow for further recommendations. 1.0–1.5 units/mL: decrease dose by 20%, repeat level before next dose. 1.6–2 units/mL: hold dose for 3 h, then decrease dose by 30%. Repeat level before next dose, then 4 h after next dose. >2 units/mL: hold all doses until anti-Xa is 0.5 units/mL, then decrease dose by 40%. Repeat level before next dose, then q12h until anti-Xa is <0.5 units/mL.
Figure 2
Figure 2
Coronal CT.
Figure 3
Figure 3
Axial CT.
Figure 4
Figure 4
Intramural hematoma.
See this image and copyright information in PMC

References

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