Colonic injury from a commonly prescribed medication

IF 0.3 Q4 GASTROENTEROLOGY & HEPATOLOGY
Jing Liang Ho, Edric J. H. Hee, Stephen K. K. Tsao, Christopher T. W. Chia, Cora Yuk-Ping Chau
{"title":"Colonic injury from a commonly prescribed medication","authors":"Jing Liang Ho,&nbsp;Edric J. H. Hee,&nbsp;Stephen K. K. Tsao,&nbsp;Christopher T. W. Chia,&nbsp;Cora Yuk-Ping Chau","doi":"10.1002/aid2.13360","DOIUrl":null,"url":null,"abstract":"<p>A 54-year-old lady was hospitalized for pericardial tamponade. An urgent pericardial drainage was performed. She was also noted to have acute kidney injury complicated by severe hyperkalemia of 7.0 mmol/L. The hyperkalemia was corrected with multiple doses of oral sodium polystyrene sulfonate (SPS) as well as a combination of intravenous insulin and dextrose injection, followed by 48 h of continuous renal replacement therapy. After 10 days, she developed fresh rectal bleeding with mild tachycardia. After stabilizing the patient including blood products transfusion, bidirectional gastrointestinal endoscopy was performed. The upper gastrointestinal endoscopy was unremarkable.</p><p>Colonoscopy revealed numerous necrotic ulcers involving the cecum (Figure 1A), and clean-based ulcers in the sigmoid colon (Figure 1B). The rest of the colon mucosa was normal. Histology of the colonic biopsies showed fragments of polygonal basophilic crystals with mosaic pattern at the ulcer base (Figure 2A). Colon ischemia was an important differential diagnosis; however, the finding of some of these crystals being surrounded by granulation tissue and inflammatory infiltrate (Figure 2B) supported the diagnosis of SPS-induced colon injury. Pseudomembranous colitis, viral inclusions, crypt distortion, crypt abscess, or granuloma were not seen, making other differential diagnoses, such as infective colitis with ulcers and inflammatory bowel disease, not likely.</p><p>SPS is a commonly used cation exchange resin in the management of hyperkalemia. In a large population-level matched cohort study, SPS was found to be associated with higher risk of serious adverse gastrointestinal events.<span><sup>1</sup></span> SPS-related adverse gastrointestinal event such as ulcer, necrosis, or perforation, although uncommon, can occur to any segment of the gastrointestinal tract, with colon being the most common site. Irrespective of the location of the injury in the gastrointestinal tract, the mortality rate remained high and was found to be 20.7% in a systemic review.<span><sup>2</sup></span></p><p>The diagnosis of SPS-induced gastrointestinal injury can be accurately made when there is a history of SPS exposure with temporal relationship to the symptom onset, together with histological evidence of SPS crystals in the biopsy sample. Risk factors include chronic kidney disease, uremia, solid organ transplantation and immunosuppressive therapy, postoperative status, hypotension, ileus, and opioid use.<span><sup>3</sup></span> Clinicians ought to exercise prudence in prescribing SPS, especially in patients who are critically ill with multiple risk factors. In such cases, newer gastrointestinal potassium binder like sodium zirconium cyclosilicate will likely be a safer option.</p><p>The authors declare no conflicts of interest.</p><p>Informed consent was obtained. Ethics committee approval is not necessary locally as this is a simple case report. Nonetheless, the principles outlined in the Declaration of Helsinki are strictly complied to.</p>","PeriodicalId":7278,"journal":{"name":"Advances in Digestive Medicine","volume":"11 1","pages":"51-52"},"PeriodicalIF":0.3000,"publicationDate":"2023-01-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/aid2.13360","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Advances in Digestive Medicine","FirstCategoryId":"1085","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1002/aid2.13360","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q4","JCRName":"GASTROENTEROLOGY & HEPATOLOGY","Score":null,"Total":0}
引用次数: 0

Abstract

A 54-year-old lady was hospitalized for pericardial tamponade. An urgent pericardial drainage was performed. She was also noted to have acute kidney injury complicated by severe hyperkalemia of 7.0 mmol/L. The hyperkalemia was corrected with multiple doses of oral sodium polystyrene sulfonate (SPS) as well as a combination of intravenous insulin and dextrose injection, followed by 48 h of continuous renal replacement therapy. After 10 days, she developed fresh rectal bleeding with mild tachycardia. After stabilizing the patient including blood products transfusion, bidirectional gastrointestinal endoscopy was performed. The upper gastrointestinal endoscopy was unremarkable.

Colonoscopy revealed numerous necrotic ulcers involving the cecum (Figure 1A), and clean-based ulcers in the sigmoid colon (Figure 1B). The rest of the colon mucosa was normal. Histology of the colonic biopsies showed fragments of polygonal basophilic crystals with mosaic pattern at the ulcer base (Figure 2A). Colon ischemia was an important differential diagnosis; however, the finding of some of these crystals being surrounded by granulation tissue and inflammatory infiltrate (Figure 2B) supported the diagnosis of SPS-induced colon injury. Pseudomembranous colitis, viral inclusions, crypt distortion, crypt abscess, or granuloma were not seen, making other differential diagnoses, such as infective colitis with ulcers and inflammatory bowel disease, not likely.

SPS is a commonly used cation exchange resin in the management of hyperkalemia. In a large population-level matched cohort study, SPS was found to be associated with higher risk of serious adverse gastrointestinal events.1 SPS-related adverse gastrointestinal event such as ulcer, necrosis, or perforation, although uncommon, can occur to any segment of the gastrointestinal tract, with colon being the most common site. Irrespective of the location of the injury in the gastrointestinal tract, the mortality rate remained high and was found to be 20.7% in a systemic review.2

The diagnosis of SPS-induced gastrointestinal injury can be accurately made when there is a history of SPS exposure with temporal relationship to the symptom onset, together with histological evidence of SPS crystals in the biopsy sample. Risk factors include chronic kidney disease, uremia, solid organ transplantation and immunosuppressive therapy, postoperative status, hypotension, ileus, and opioid use.3 Clinicians ought to exercise prudence in prescribing SPS, especially in patients who are critically ill with multiple risk factors. In such cases, newer gastrointestinal potassium binder like sodium zirconium cyclosilicate will likely be a safer option.

The authors declare no conflicts of interest.

Informed consent was obtained. Ethics committee approval is not necessary locally as this is a simple case report. Nonetheless, the principles outlined in the Declaration of Helsinki are strictly complied to.

Abstract Image

常用处方药引起的结肠损伤
一位 54 岁的女士因心包填塞住院。医生紧急进行了心包引流术。同时还发现她患有急性肾损伤,并伴有 7.0 mmol/L 的严重高钾血症。多剂量口服聚苯乙烯磺酸钠(SPS)以及静脉注射胰岛素和葡萄糖联合治疗纠正了高钾血症,随后进行了 48 小时的持续肾脏替代治疗。10 天后,她出现了新鲜直肠出血,并伴有轻度心动过速。在输注血制品等稳定病情后,对患者进行了双向消化内镜检查。结肠镜检查显示盲肠有大量坏死溃疡(图 1A),乙状结肠也有干净的溃疡(图 1B)。其余结肠粘膜正常。结肠活检组织学显示,溃疡底部有多角形嗜碱性结晶碎片,并呈镶嵌状(图 2A)。结肠缺血是一个重要的鉴别诊断;但是,发现其中一些晶体周围有肉芽组织和炎症浸润(图 2B),这支持了 SPS 引起的结肠损伤的诊断。没有发现假膜性结肠炎、病毒包裹体、隐窝变形、隐窝脓肿或肉芽肿,因此其他鉴别诊断(如感染性结肠炎伴溃疡和炎症性肠病)的可能性不大。1 与 SPS 相关的胃肠道不良事件如溃疡、坏死或穿孔虽然并不常见,但可发生在胃肠道的任何部位,结肠是最常见的部位。无论损伤发生在胃肠道的哪个部位,死亡率都很高,在一项系统回顾中发现死亡率为 20.7%。2 如果有 SPS 暴露史,且与症状出现有时间上的联系,同时活检样本中有 SPS 晶体的组织学证据,就可以准确诊断 SPS 引起的胃肠道损伤。风险因素包括慢性肾病、尿毒症、实体器官移植和免疫抑制治疗、术后状态、低血压、回肠梗阻和使用阿片类药物。在这种情况下,新型胃肠道钾粘合剂(如环硅酸锆钠)可能是更安全的选择。由于这只是一份简单的病例报告,因此无需获得当地伦理委员会的批准。尽管如此,本文仍严格遵守了《赫尔辛基宣言》中的原则。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
求助全文
约1分钟内获得全文 求助全文
来源期刊
Advances in Digestive Medicine
Advances in Digestive Medicine GASTROENTEROLOGY & HEPATOLOGY-
自引率
33.30%
发文量
42
期刊介绍: Advances in Digestive Medicine is the official peer-reviewed journal of GEST, DEST and TASL. Missions of AIDM are to enhance the quality of patient care, to promote researches in gastroenterology, endoscopy and hepatology related fields, and to develop platforms for digestive science. Specific areas of interest are included, but not limited to: • Acid-related disease • Small intestinal disease • Digestive cancer • Diagnostic & therapeutic endoscopy • Enteral nutrition • Innovation in endoscopic technology • Functional GI • Hepatitis • GI images • Liver cirrhosis • Gut hormone • NASH • Helicobacter pylori • Cancer screening • IBD • Laparoscopic surgery • Infectious disease of digestive tract • Genetics and metabolic disorder • Microbiota • Regenerative medicine • Pancreaticobiliary disease • Guideline & consensus.
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术官方微信