[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.