Severe Anemia in a Post-Liver Transplant patient

Patient Presentation:
JB, a 17 y.o. male presented to the inpatient Pediatric Transplant Unit following an outpatient lab draw. Outpatient labs showed Hct/Hgb of 18.9 and 6.8, respectively. Upon arrival to the unit, patient was alert and oriented x3, and complaining of 8/10 pain in the left flank. He was pale but stable on ambulation. Lung sounds clear bilaterally. Positive bowel sounds, no complaints of nausea/vomiting/diarrhea. No changes in appetite. Patient denies bloody stools or hemoptysis. Denies pain on urination or change in urinary habits. Denies trauma to left flank. Patient had multiple areas of ecchymosis, mostly on upper arms. Past medical history significant for a liver transplant in 3 years prior necessitated by Primary Sclerosing Cholangitis. JB had also recently undergone a distal splenorenal shunt secondary to portal hypertension one month prior to this admission, and had been placed on prophylactic Lovenox® and aspirin following that surgery.

Vital signs on admission:
Temp 36.7 PO, HR 80, RR 14, BP 100/56, SpO2 98% on RA

Diagnosis:
Labs as follows:
CBC: WBC 1.8, RBC 2.06, Hgb 6.8, Hct 19.1, MCV 92.7, MCHC 33.1, RDW 35.7, Plt 40, PT: 17.4, INR: 1.5, PTT: 39.2, Anti-Xa 0.86 (normal 0.5-1)
LFTs: AST 63, ALT 94, Alk Phos 243, GGT 40, direct bilirubin 0.2, total bilirubin 2.3
fecal occult blood screen: negative

Ultrasound of left flank revealed iliopsoas hematoma, approximately 16 cm. This is likely a spontaneous muscle bleed r/t Lovenox therapy.

Treatment:
Lovenox and Aspirin therapy stopped immediately. PRBCs transfused x 2 units. Labs monitored closely. Hematoma monitored via ultrasound, decreased in size to 13 cm by discharge. Pain controlled with IV Dilaudid® as patient has allergy to morphine. Patient eventually weaned to PO pain medication. H/H remained stable following PRBC administration. Patient discharged home, with plans to get biweekly labs and ultrasounds as necessary to monitor hematoma and patency of splenorenal shunt.

Outcome:
Approximately one month following this admission, JB had an ultrasound to assess patency of the splenorenal shunt, which showed reversal of flow in the portal vein with small clot formation. Lovenox® was restarted with no recurrence of anemia or worsening of the hematoma thus far.