[3] Methods (Differential Diagnoses, Investigations, and Treatment)
Laboratory investigations (Table 1 ) revealed decreased hemoglobin (Hb), leukocytosis, decreased mean corpuscular volume (MCV), low red blood cell (RBC) count, and platelets at the lower limit. The prothrombin time (PT) and activated partial thromboplastin time (APTT) were within the normal range.
The pediatric surgical team suspected intussusception initially and performed an ultrasound, which did not show signs of intussusception but revealed a rounded hypo to iso-echoic lobulated area adjacent to the porta hepatis and head of the pancreas, devoid of vascularity.
Further evaluation with cross-sectional imaging was recommended, leading to a computed tomography (CT) scan of the abdomen with contrast. The CT abdomen with contrast revealed a large intramural/submucosal duodenal hematoma along its entire length, causing luminal narrowing (Figure 1 ).
The radiology team suggested additional workup to rule out underlying hematological disorders or myeloproliferative disease. The coagulation profile showed a deficiency of FXIII (Table 1 ), which was determined to be the cause of the duodenal hematoma.
An esophagogram demonstrated a thin streak of contrast trickling into the proximal duodenum, suggestive of near-complete proximal duodenal obstruction (Figure 2 ). The patient was subsequently advised non-surgical management. Initially, she was kept nil per oral (NPO) and received intravenous hydration. A peripherally placed central venous catheter was placed under sedation after obtaining consent from the parents, and total parenteral nutrition (TPN) was initiated. The care plan was explained to the family, and the patient’s hemodynamic parameters and output were closely monitored. Once stable, clear fluids were introduced, which the patient tolerated well.