C0138 - Sevelamer-Induced Colitis

Ayushi Shah, MBBS¹, Shaadi Abughazaleh, MD¹, Daniel Bushyhead, MD¹, Mukul Divatia, MBBS¹, Kerri Glassner, DO^2
1Houston Methodist Hospital, Houston, TX; ²Houston Methodist Academic Institute, Houston, TX

Introduction: This case describes an under-recognized adverse effect of sevelamer on the gastrointestinal tract.

Case Description/Methods: A 57-year-old woman with type 2 diabetes and ESRD on peritoneal dialysis (PD) was admitted to the hospital for right foot cellulitis treated with intravenous clindamycin. She developed right lower quadrant abdominal pain with non-bloody diarrhea on hospital day 6. CT of the abdomen and pelvis revealed cecal and ascending colon wall thickening. Peritoneal fluid drawn from the PD catheter was cloudy with 5046 WBC/cm³. 2 days later, she developed nausea and vomiting at which time repeat imaging showed partial small bowel obstruction with a transition point in the mid-ileum. Her symptoms improved with nasogastric tube decompression. The colon wall thickening and bowel obstruction were initially attributed to peritoneal fluid infection related to the PD catheter and further peritoneal effluent culture showed decreasing WBC count with antibiotics. Her symptoms did not improve and one week later she developed hematochezia.

The physical examination was remarkable for right lower quadrant tenderness. Stool studies were negative for infection. Colonoscopy was performed and showed erythematous and edematous mucosa at the ileocecal valve and an area of ulcerated circumferential mucosa in the proximal ascending colon. Biopsy showed mucosal ulceration associated with sevelamer crystals with a characteristic pink and yellow fish-scale appearance. Sevelamer had been initiated during this hospitalization 4 days prior to development of symptoms. The patient’s symptoms resolved within 48 hours of stopping this medication.

Discussion: This case attempts to increase physician awareness of sevelamer-induced gastrointestinal injury. Our patient presented not only with colitis but also small bowel obstruction from enteritis and ileocecal valve inflammation. Swanson et al were the first to report a series of 15 patients with a spectrum of mucosal injury involving the esophagus, small bowel and colon. Multiple reports have described the effects with the most severe being colonic obstruction, ischemic necrosis and perforation. A review of 19 cases identified no association between the dose of sevelamer and severity of injury. The potential mechanism for injury is deposition of this insoluble polymer in gastrointestinal mucosa like its resin counterpart, kayexalate. Prompt discontinuation of the medication can potentially prevent further injury and catastrophic complications such as perforation.



Disclosures:


Ayushi Shah, MBBS¹, Shaadi Abughazaleh, MD¹, Daniel Bushyhead, MD¹, Mukul Divatia, MBBS¹, Kerri Glassner, DO². C0138 - Sevelamer-Induced Colitis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.