Abstract: FR-PO633
A Concrete Cause of Abdominal Pain
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
- 402 Bone and Mineral Metabolism: Clinical
Authors
- Gentry, Jimmy D., Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Hanna, Peter, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Naik, Rishi, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Wanko, Lori, Vanderbilt University Medical Center, Nashville, Tennessee, United States
- Gould, Edward, Vanderbilt University Medical Center, Nashville, Tennessee, United States
Introduction
Sevelamer hydrochloride is a non-calcium based phosphate binder routinely used in the treatment of hyperphosphatemia in patients with impaired renal excretion of phosphorus. Sevelamer is commonly associated with mild gastrointestinal (GI) symptoms - most commonly, constipation, nausea and bloating. Here we describe a case of a more serious sevelamer concretion masquerading as a gastric malignancy in a patient presenting with abdominal pain.
Case Description
Our patient is a 48 year-old female with a history of hypertension, DM2, morbid obesity, and ESRD on hemodialysis three times a week, who presented with sharp left flank pain of two weeks duration as well as nausea and early satiety. A contrasted CT scan raised concern for invasive gastric malignancy.
She underwent endoscopy with biopsy for diagnostic purposes. Visual examination revealed a discolored infiltrative mass. Histologic examination revealed irregularly shaped “fish-scales” consistent with sevelamer crystals and other debris all consistent with sevelamer concretion. After multidisciplinary discussion the decision was made to forego surgical removal and treat conservatively. Prior to presentation, she had been on 3200mg three times daily of sevelamer; this was discontinued with plan for repeat EGD to ensure resolution of the gastric mass and healing of the gastric ulcer.
Discussion
Resin-based phosphate binders such as sevelamer can crystallize leading to the formation of concretions. Since the first description of this in 2013 there have been seventeen reported cases of GI lesions attributable to sevelamer. Eighty-one percent of these were in the intestine and the most frequent presentation is GI bleeding. Pathology ranges from acute inflammation to chronic mucosal injury, strictures, ulcerations, and necrosis, many of which show sevelamer at least in close proximity to inflammation or ulceration on histology.
Gastric involvement is rare, and when present is usually in the form of an ulceration. We could not identify previous reports of a gastric mass due to sevelamer. Given the frequency of sevelamer use, it is critical for clinicians to remain attentive to the possibility of sevelamer concretions as a cause for GI symptoms and pathology in patients using it for phosphorous elimination.