Abstract: FR-PO611
Gastrointestinal Bleed in ESRD: An Unexpected Cause
Session Information
- Trainee Case Reports - IV
October 26, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 701 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Kodali, Ravi, Yale University School of Medicine, New Haven, Connecticut, United States
- Chang, Eric, Yale University School of Medicine, New Haven, Connecticut, United States
- Brewster, Ursula C., Yale University School of Medicine, New Haven, Connecticut, United States
Group or Team Name
- Yale University
Introduction
ESRD patients have a fivefold higher risk of gastrointestinal (GI) bleed compared to those without CKD. Common causes include angiodysplasia, peptic ulcer disease, diverticular disease, ischemic colitis. A lesser known causes of GI bleed in this population is sevelamer induced GI ulcer.
Case Description
A 59-year-old African American man with type 2 diabetes mellitus, HTN, ESRD on hemodialysis, presented with severe headache and right sided weakness. He had intraventricular hemorrhage from severe hypertension. Routine labs showed hyperphosphatemia, so he was continued on sevelamer. On hospitalization day 20, he had multiple episodes of dark tarry stools with hemoglobin drop. Upper GI endoscopy revealed a large ulcer in the duodenum; he was started on pantoprazole. GI bleed recurred over the next weeks. A colonoscopy revealed a 3-5 cm segment of ulcerated and friable mucosa in the ascending colon. Biopsy of the colonic ulcer revealed presence of “fish scale” crystals previously associated with sevelamer, with inflammatory changes (Fig 1). A diagnosis of sevelamer induced colonic ulcer was made and sevelamer was stopped.
Discussion
Here we report 6 cases from our institution of GI ulcerations with deposition of sevelamer (Table 1). This is an underappreciated association and should be suspected in the right clinical scenario. Given the continued increase in use of sevelamer as a phosphate binder, it is important for the nephrologists to be cognizant of this entity.
Table 1
| Age (years) | Dialysis vintage (years) | Time on sevelamer (years) | Presenting symptoms | Location of lesion | |
| Patient 1 | 59 | 5 | 5 years intermittent use | Melena, hgb drop | Ascending colon |
| Patient 2 | 58 | 7 | 5 | Abdominal Pain, diarrhea | Transverse colon |
| Patient 3 | 50 | 3 (PD) | 3 | Sigmoid perforation | Sigmoid colon |
| Patient 4 | 56 | 2 | 2 | Rectosigmoid colitis | Colon NOS (random biopsy) |
| Patient 5 | 75 | 3 | 2 | Rectal ulcers, hematochezia | Rectosigmoid colon |
| Patient 6 | 69 | 3 | 3 | Heme positive stools, anemia | Colon |
Sevelamer crystals in biopsy from colon