Volume 4 | August 2017
Image | Colon

Colonic Mass Secondary to Sevelamer-Associated Mucosal Injury

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Vishant Bansal, MD1, Pankaj Aggarwal, BS2, Akaash Mittal, BS3, Meera Vachhani, PharmD4, Prachi Aggarwal, MD5, and Nitin Aggarwal, MD6

1Department of Internal Medicine, Kingsbrook Jewish Medical Center, Brooklyn, NY
2St. George’s University School of Medicine, Grenada, West Indies
3Robert Wood Johnson School of Medicine, Piscataway, NJ
4Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
5Department of Internal Medicine, Forest Hills Hospital, Queens, NY
6Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH

ACG Case Rep J 2017;4:e92. http://dx.doi.org/10.14309/crj.2017.92. Published online: August 2, 2017.

Case Report

In patients with chronic kidney disease, sevelamer is used to treat hyperphosphatemia; the mechanism of action is intestinal binding of phosphate and subsequent fecal clearance. Known gastrointestinal (GI) side effects include nausea, vomiting, diarrhea, dyspepsia, and, more rarely, abdominal pain and constipation.1 A 42-year-old woman with hyperphosphatemia secondary to end-stage renal disease was being treated with 800 mg sevelamer every 8 hours. She presented with left lower quadrant abdominal pain and watery diarrhea.

Figure 1. Colonoscopic image of fungating mass in the proximal sigmoid colon.

Stool cultures and polymerase chain reaction were negative for Clostridium difficile infection. Esophagogastroduodenoscopy revealed grade D esophagitis (histochemical staining was negative for cytomegalovirus, herpes simplex virus, and sevelamer crystals) and a 3-cm hiatal hernia but was otherwise normal. Colonoscopy showed a 6 cm, fungating, oozing mass in the proximal sigmoid colon with no evidence of obstruction (Figure 1). Biopsy of the mass showed necrotic tissue with bacterial overgrowth. Acid-fast and periodic acid-Schiff stain highlighted eosinophilic fish-scale crystals consistent with sevelamer deposition (Figure 2).2 After sevelamer was discontinued, repeat colonoscopy at 3 months showed normal pink mucosa with healthy blood vessels throughout the entire colon (Figure 3).

Figure 2. (A) Biopsy of specimen showing inflammatory, necrotic debris, and sevelamer crystals (arrow). (B) Magnified view of sevelamer crystals.

Sevelamer is a non-absorbable, phosphate-binding resin that acts in the GI tract to limit the absorption of phosphate. It has shown great clinical efficacy in patients with hyperphosphatemia secondary to chronic kidney disease.1 While GI side effects have been well described, only rare cases have reported serious GI sequelae. One case described a case of colonic fecolith obstruction secondary to sevelamer use given the accumulation of crystals in the biopsy specimen.3 Patients have been described with ulceration of the sigmoid colon.4 On histology, sevelamer crystals were also discovered; however, these crystals were not associated with the formation of an obstruction or mass. A similar case reported a patient with nonbloody diarrhea found to have a colonic mass secondary to sevelamer ingestion.5 Unfortunately, follow-up colonoscopy was not reported in this case. To our knowledge, ours is the first case to show complete remission of colonic mass after sevelamer discontinuation.

Figure 3. Follow-up colonoscopy at 3 months showing healthy mucosa throughout the colon.


Disclosures

Author contributions: V. Bansal and P. Aggarwal collected the data, and wrote and edited the manuscript. A. Mittal, P. Aggarwal, and M. Vachhani critically revised the manuscript. N. Aggarwal critically revised the manuscript and is the article guarantor. V. Bansal and P. Aggarwal share first authorship of this manuscript.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

Correspondence: Nitin Aggarwal, 9500 Euclid Ave, Cleveland, OH 44195 (Naggarwal7@gmail.com).

Received January 19, 2017; Accepted May 25, 2017


References

  1. Grinfeld J, Inaba A, Hutchison A. Update and critical appraisal of sevelamer in the management of chronic renal failure. Open Access J Urol. 2010;2:161–70. Article | PubMed
  2. Swanson B, Limketkai B, Liu T, et al. Sevelamer crystals in the gastrointestinal tract (GIT). Am J Surg Pathol. 2013;37(11):1686–93. Article | PubMed
  3. Kim J, Olson K, Butani L. Sevelamer crystals in the mucosa of the gastrointestinal tract in a teenager with end-stage renal disease. Pediatr Nephrol. 2015;31(2):339–41. Article | PubMed
  4. Tieu C, Moreira RK, Song LM, et al. A case report of sevelamer-associated recto-sigmoid ulcers. BMC Gastroenterol. 2016;16(1):16–20. Article | PubMed
  5. Okwara C, Choi C, Park JY. Sevelamer-induced colitis presenting as a pseudotumor. Clin Gastroenterol Hepatol. 2015;13(7):A39–A40. Article | PubMed

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© 2017 Bansal et al. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0.