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E Port J Gastroenterol. 2015;22(3):126---127

www.elsevier.pt/ge

MAGES IN GASTROENTEROLOGY AND HEPATOLOGY

ematochezia in a Patient with Renal Failure andyperkalemia

ematoquésia num Doente com Insufiência Renal e Hipercaliémia

ânia Meiraa,∗, Vitor Fernandesa, Helder Coelhob

Gastroenterology Department, Hospital Garcia de Orta, Almada, PortugalPathology Department, Hospital Garcia de Orta, Almada, Portugal

eceived 8 January 2015; accepted 18 February 2015

vailable online 19 April 2015

68-year-old man with history of hypertension, type 2 dia-etes mellitus, coronary artery disease, aortic stenosis andhronic kidney disease. Relevant medications included biso-rolol, furosemide, atorvastatin, perindopril/amlodipine,etformin/sitagliptin and aspirin. The patient was admit-

ed in the emergency department for acute decompensatedeart failure and acute-on-chronic renal failure with hyper-alemia. He began treatment with cation exchange resin40 g/day), which was continued for 3 days. On the fourthay of hospitalization, the patient presented hematocheziaith hemodynamic repercussion and anemia (hemoglobin,.5 g/dl). Two units of packed red blood cells have beenransfused and an endoscopic examination was requested,he colonoscopy revealed three ulcers with about 10 mm,ongested and edematous surrounding mucosa, in the prox-mal ascending colon (Fig. 1). Histological evaluation of thelcer biopsies identified several rhomboid crystals of sodiumolystyrene sulfonate. This clinical case was assumed to be aodium polystyrene sulfonate-induced colitis (Figs. 2 and 3).he patient was discharged without evidence of rebleeding.

∗ Corresponding author.E-mail address: tania meira@hotmail.com (T. Meira).

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ttp://dx.doi.org/10.1016/j.jpge.2015.02.003341-4545/© 2015 Sociedade Portuguesa de Gastrenterologia. PublishedC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4

Figure 1 A colonoscopy shows ulceration in the right colon.

Sodium polystyrene sulfonate (SPS) is a drug used in the

reatment of hyperkalemia. Its action begins in the stomach,ith the exchange of sodium ions for hydrogen ions that,long the digestive tract, are exchanged for potassium ions,hich are, in turn, eliminated in the feces, consequently

by Elsevier España, S.L.U. This is an open access article under the.0/).

Hematochezia in a patient with renal failure and hyperkalemia

Figure 2 Microscopically, intestinal mucosa shows ischemicchanges and the presence of dense polygonal basophilic crystalswithin the granulation tissue and the ulcer bed (40× HE).

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Figure 3 Polystyrene sulfonate crystals with their character-istic mosaic pattern (400× HE).

reducing the levels of serum potassium. SPS can cause con-stipation and fecal impaction, and is often administratedcombined with sorbitol or other hypertonic laxative. Themechanism of injury to the mucosa of the gastrointesti-nal tract is not yet clear: It is believed that the sorbitoladditive, due to its cathartic effect, induces changes in theintestinal microcirculation vasculature and that its osmotic

action results in/contributes to direct mucosal injury.1 Inour case, sorbitol or other laxative was not concomitantlyadministered, likewise in a previous case report describedby Tapaya et al.2 Such fact suggests that the adverse effect

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s not correlated with the use of laxatives, but SPS mayave a significant role inducing digestive tract lesions. Colitisue to SPS occurs in 1% of the cases, especially in post-urgical patients and patients with advanced renal disease,he last condition as was the case of our patient.3,4 Clinicalresentation varies, ranging from abdominal pain, nausea,iarrhea and hematochezia. Endoscopic findings are non-pecific: mucosal edema, ulcers, pseudomembranes and,n more severe cases, necrosis and intestinal perforation.4

escriptions of previous cases indicate that symptoms canppear up to 11 days after the drug’s administration, inur patient, the symptoms appeared 3 days after takingPS, suggesting its early adverse effect. Several differentialiagnoses, such as inflammatory bowel disease, infectionnd ischemia should be considered; therefore, the histo-ogical analysis of the biopsies is essential for definitiveiagnosis. Microscopically, the biopsy specimens showedolygonal crystals, basophilic and nonpolaring, with mosaicattern.5 Patient management includes supportive care,voiding drugs and, in the most severe cases, intestinalesection may be required.

thical disclosures

rotection of human and animal subjects. The authorseclare that no experiments were performed on humans ornimals for this study.

onfidentiality of data. The authors declare that no patientata appear in this article.

ight to privacy and informed consent. The authors havebtained the written informed consent of the patients orubjects mentioned in the article. The corresponding authors in possession of this document.

onflicts of interest

he authors have no conflicts of interests to declare.

eferences

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. Tapaia C, Schneider T, Manz M. From hyperkaliemia toischemic colitis: a resinous way. Clin Gastroenterol Hepatol.2009;7:e46---7.

. Rashid A, Hamilton SR. Necrosis of the gastrointestinal tractin uremic patients as a result of sodium polystyrene sulfonate(kayexalate) in sorbitol: an underrecognized condition. Am J SurgPathol. 1997;21:60---9.

. Abrham SC, Bhagavan BS, Lee LA, Rashid A, Wu TT. Uppergastrointestinal tract injury in patients receiving kayexalate in

sorbitol. Am J Surg Pathol. 2001;25:637---44.

. Mc Gowan CE, Saha S, Chu G, Resnick MB, Moss SF. Intestinalnecrosis due to sodium polysterene sulfonate in sorbitol. SouthMed J. 2009;102:493---7.