Leon D. Averbukh, DO1, Thayer Nasereddin, MD2, Aswathy M. Cheriyan, MD, MPH2, Alok Mohanty, MD2, Abhijit Kulkarni, MD2 1AHN, Pittsburgh, PA; 2Allegheny Health Network, Pittsburgh, PA
Introduction: Renal failure is associated with a host of electrolyte imbalances of which hyperphosphatemia is an important complication. Sevelamer is a phosphate binder used to help excrete excess phosphate in feces in patients with end stage renal disease. Though rarely reported, sevelamer administration has been associated with the development of ischemic colitis. We present the case of a 57yo male who presented with right lower quadrant pain and was subsequently diagnosed with right sided ischemic colitis associated with sevelamer administration.
Case Description/Methods: A 57yo male with a past medical history significant for end stage renal disease on dialysis, end stage heart disease with left ventricular assist device on coumadin, morbid obesity, type 2 diabetes mellitus and a surgical history significant for remote appendectomy and partial sigmoid colon resection presented in the setting of weeklong unremitting and sharp right lower quadrant abdominal pain. At presentation, the patient was hemodynamically stable. Laboratory evaluation was significant for a WBC of 15.72 109/L, hemoglobin of 10.2 g/dl , platelets 210 109/L. Electrolytes were within normal limits, BUN 39 mg/dL, creatinine 7.93 mg/dL, and LDH 141 U/L. CT abdomen and pelvis with contrast was concerning for colitis involving the cecum and proximal ascending colon [Figure 1]. Colonoscopy revealed cecal mucosa grossly consistent with ischemic colitis [Figure 1]. Biopsies of the affected area identified ischemic-like changes with the presence of sevelamer crystals [Figure 1]. Follow up CT angiogram ruled out mesenteric ischemia. Further review of the patient’s medications revealed that the patient was on sevelamer therapy and it was subsequently discontinued.
Discussion: Sevelamer is a rare nidus for gastrointestinal lesions first described in 2008. Most commonly, lesions present as erosions and ulcerations or pseudo inflammatory polyps with a predisposition for the colon. Histological findings involve crystal identification inside mucosa or around epithelial surface in irregular shapes with a broad and curved mosaic pattern described as “fish scale”. On H&E staining, the crystals appear two toned with bright pink linear accentuations and rusty yellow background. It is believed that diabetic patients and those with chronic constipation are more likely to be at risk for sevelamer toxicity as slower colonic transit time increases the risk for the sevelamer crystals, excreted in feces, to develop crystalline concretions.
Figure: Figure 1. A. CT Abdomen and Pelvis demonstrating findings consistent with right sided colitis (red oval). B. Colonoscopy demonstrating evidence of ischemic ulceration in the cecum (green arrows). C. Biopsy of noted colonic lesions demonstrating the presence of sevelamer crystals under 10x and 20x magnification (blue arrows).
Disclosures: Leon Averbukh indicated no relevant financial relationships. Thayer Nasereddin indicated no relevant financial relationships. Aswathy Cheriyan indicated no relevant financial relationships. Alok Mohanty indicated no relevant financial relationships. Abhijit Kulkarni indicated no relevant financial relationships.
Leon D. Averbukh, DO1, Thayer Nasereddin, MD2, Aswathy M. Cheriyan, MD, MPH2, Alok Mohanty, MD2, Abhijit Kulkarni, MD2. P0204 - An Unusual Suspect: Sevelamer Induced Ischemic Colitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
