Thomas Jefferson University Hospital Philadelphia, PA, United States
Mikayla Cochrane, BS1, Sahaj Mujumdar, MD1, Fred Karaisz, MD1, Divya Chalikonda, MD2, Daniel Christensen, MD2, Patricia Kozuch, MD1, Leo Katz, MD1, Christopher Adkins, MD2, Manju Ambelil, MD3, Christopher H. Henry, MD1 1Thomas Jefferson University Hospital, Philadelphia, PA; 2Thomas Jefferson University Hospitals, Philadelphia, PA; 3Thomas Jefferson University, Philadelphia, PA
Introduction: Calciphylaxis is an uncommon disease of the microvasculature that can manifest as cutaneous lesions in chronic dialysis patients. Involvement of the gastrointestinal tract is exceedingly rare and can present as a hemorrhagic gastric ulcer, as described.
Case Description/Methods: A 57-year-old woman with congestive heart failure, hypertension, end-stage renal disease (ESRD) on dialysis, and a sleeve gastrectomy seven years ago, presented with hematemesis and diffuse abdominal pain. She denied regular use of non-steroidal anti-inflammatory drugs. On arrival, vitals were stable. On physical exam, she appeared comfortable and had a normal cardiac and respiratory exam with notably no abdominal tenderness. Her presenting hemoglobin was 8.9 g/dL from 11.0 g/dL two years prior. She underwent an esophagogastroduodenoscopy (EGD) on day two of her hospitalization which revealed a single cratered 6mm ulcer in the pre-pyloric region. A visible vessel with small adherent clot was identified. Epinephrine injection was attempted, but unsuccessful due to significant fibrosis, so bipolar electrocautery was applied to the visible vessel and the ulcer margins. Biopsy of the ulcer was negative for H. pylori, but revealed multiple foci of calcium deposition within the lamina propria capillaries suggestive of calciphylaxis (Figure 2). She was discharged on pantoprazole 40 mg twice daily with plans for repeat EGD within 3 months.
Discussion: Calciphylaxis, also known as calcific uremic arteriopathy, is a rare condition with a poor prognosis in which calcification of the microvasculature leads to localized ischemia and necrosis. Calciphylaxis predominantly affects patients with ESRD, as it is believed that hyperparathyroidism may play a role in its pathogenesis. Hyperparathyroidism, hyperphosphatemia, and high calcium-phosphate levels are thought to downregulate inhibitors of vascular calcification. Reports have also proposed that gastric bypass is a risk factor for calciphylaxis. For individuals with a gastric bypass, mineral bone abnormalities such hypovitaminosis D and secondary hyperparathyroidism are common complications after surgery. Calciphylaxis usually manifests as painful cutaneous lesions. It has, however, been previously described as a rare cause of gastrointestinal bleeding. Notably, our patient did not have cutaneous manifestations of calciphylaxis. It is possible that the altered vasculature of her stomach in the setting of previous surgery may have increased her risk of peptic calciphylaxis.
Figure: Figure 2. H&E Stain at 400x magnification. Gastric antral mucosa with intracapillary calcium deposition highly suggestive of calciphylaxis.
Disclosures: Mikayla Cochrane indicated no relevant financial relationships. Sahaj Mujumdar indicated no relevant financial relationships. Fred Karaisz indicated no relevant financial relationships. Divya Chalikonda indicated no relevant financial relationships. Daniel Christensen indicated no relevant financial relationships. Patricia Kozuch indicated no relevant financial relationships. Leo Katz indicated no relevant financial relationships. Christopher Adkins indicated no relevant financial relationships. Manju Ambelil indicated no relevant financial relationships. Christopher Henry indicated no relevant financial relationships.
Mikayla Cochrane, BS1, Sahaj Mujumdar, MD1, Fred Karaisz, MD1, Divya Chalikonda, MD2, Daniel Christensen, MD2, Patricia Kozuch, MD1, Leo Katz, MD1, Christopher Adkins, MD2, Manju Ambelil, MD3, Christopher H. Henry, MD1. P2601 - Acute Upper Gastrointestinal Bleed Due to Gastric Calciphylaxis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.