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Intramural Bowel Hematoma Presenting as Small Bowel Obstruction in a Patient on Low-Molecular-Weight Heparin
Beatrix Hyemin Choi1, Michael Koeckert2, Sandra Tomita1
1Division of Pediatric Surgery, Department of Surgery, NYU School of Medicine, Hassenfeld Children's Hospital at NYU Langone, New York, NY, USA.
Insights
Low-molecular-weight heparin (LMWH) is increasingly used for pediatric thromboembolic disease due to its safety and efficacy. However, this case shows that serious bleeding can still occur even with therapeutic anti-Xa levels.
Area of Science:
- Pediatric Hematology
- Thromboembolic Disease Management
- Anticoagulant Therapy
Background:
- Low-molecular-weight heparin (LMWH) offers advantages over unfractionated heparin for pediatric thromboembolic disease, including easier administration and reduced monitoring.
- Despite its benefits, LMWH, like all anticoagulants, carries an inherent risk of bleeding complications.
Observation:
- A 4-year-old boy with catheter-related deep venous thrombosis and intractable seizures was treated with LMWH.
- The patient developed a small bowel obstruction, later found to be an intramural bowel hematoma during exploratory laparotomy.
Findings:
- The patient's anti-Xa levels were consistently within the therapeutic range prior to the bleeding event.
- This case demonstrates a spontaneous bleeding complication despite adherence to therapeutic LMWH dosing.
Implications:
- Highlights the critical need for vigilance regarding potential bleeding in pediatric patients receiving LMWH.
- Suggests that therapeutic anti-Xa levels alone may not entirely preclude the risk of significant spontaneous hemorrhage.
- Emphasizes the importance of clinical monitoring for bleeding complications in pediatric anticoagulant therapy.
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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