An Unusual Cause of Early Respiratory Distress in a Neonate: Infective Endocarditis

Abstract

Intestinal intramural haematomas, seen most commonly after blunt abdominal trauma, 1 are a rare complication of small bowel biopsy. We present a case of a child who developed a large duodenal haematoma after an endoscopic small bowel biopsy and was successfully managed with prolonged non-operative treatment.During an elective tooth extraction under general anaesthesia, a 9-year-old boy with developmental delay underwent small bowel biopsy for suspected coeliac disease. Forty-eight hours later, he presented in hypovolaemic shock with abdominal tenderness, coffee-ground vomiting and a haemoglobin drop of 6 g/dL. Plain abdominal radiography revealed soft tissue shadowing in the right hypochondrium and computerised tomography confirmed an extensive intramural haematoma in the distal third of the duodenum and proximal jejunum ( Fig. 1). Measuring 10 ¥ 4 ¥ 5.5 cm, it caused complete occlusion of the bowel lumen and pressure on the pancreatic head, with resultant pancreatitis (peak amylase 3537 U/L).After initial crystalloid fluid resuscitation, non-operative management was instituted with nasogastric drainage and total parenteral nutrition (TPN). He first passed stool 18 days postoperatively and abdominal ultrasound showed partial haematoma resolution to 7.4 ¥ 3.4 cm. The volume of bilious aspirates gradually decreased, and after 27 days, the haematoma size had significantly reduced to 2.4 ¥ 1.2 cm and enteral feeds were re-introduced. TPN was discontinued on day 33 and he was discharged home 5 weeks after admission.Most intestinal intramural haematomas are duodenal. 2Although not present in our patient, pre-disposing factors include anticoagulant use, bleeding disorders and chronic renal or hepatic failure.1 The richly vascularised duodenal submucosa is a potentially significant bleeding source 3 but also allows reabsorption of the haematoma, 2 justifying non-operative management as the initial treatment of choice.Medical management is increasingly used, 4 but referral to a surgeon for incision or drainage should be made in cases with bowel perforation or ischaemia in patients with haemodynamic compromise, or in those who do not respond to non-operative treatment. 3,4 Although most cases resolve within 14 days, 3,4 the question of how long non-operative treatment should be continued for, in the absence of a response, remains unclear. This case demonstrates that persisting with non-operative management beyond 2 weeks, even in the presence of ongoing bilious aspirates, can be an effective strategy. We suggest that by adopting such an approach, unnecessary surgery may be avoided.