P984 -Sodium Polystyrene Sulfate-Induced Colonic Ulceration

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Sodium polystyrene sulfate (SPS) is an ion exchange resin used in the management of hyperkalemia. Although the documented relationship between SPS administration and colonic perforation is rare, it is important to consider in patients with acute kidney injury, chronic kidney disease (CKD), immediate post-operative period and paralytic ileus. We present a patient with hyperkalemia and acute kidney injury who developed colonic ulceration secondary to SPS administration.

A 78-year-old male with diabetes mellitus type 2, CKD and coronary artery disease presented with complains of epigastric pain along with multiple voluminous watery bowel movements for the past 2 days. On presentation, he had a blood pressure of 109/46 mmHg, pulse of 62 bpm and no fever. Laboratory findings revealed the patient to be anemic with a hemoglobin of 11.8 g/dL, creatinine of 6.6 mg/dL and BUN of 91 mg/dL, potassium of 7.3 mmol/L but no EKG changes along with normal cardiac enzymes. He received 18 units of Insulin along with SPS and sodium bicarbonate. Potassium continued to downtrend and dialysis was not initiated. Stool cultures and studies for ova and parasites along with clostridium difficile toxin were negative. CT scan revealed distal stomach and proximal duodenal thickening. Esophagogastroduodenoscopy revealed reflux esophagitis, three non-bleeding gastric ulcers with clear base and a non-bleeding duodenal ulcer with biopsy negative for any dysplasia and Helicobacter Pylori. Subsequently, the patient underwent colonoscopy which revealed diffuse moderate inflammation in the descending colon, with severe inflammation in the transverse colon. Colonic histopathology revealed ulceration of the colonic mucosa with basophilic crystal consistent with SPS induced injury and no features of ischemia, infectious changes or granulomas.

SPS acts in the large intestine by exchanging sodium ions for potassium ions. While the precise mechanism for bowel necrosis remains unclear, it is speculated that local osmotic action and vasospasm of intestinal vasculature is the reason. SPS-induced intestinal injury reveals rhomboid or triangular basophilic crystals adherent to the surface epithelium on histopathology. Our case highlights the need for physicians to be cognizant about the potential adverse effect of SPS especially with rising prevalence of CKD and end stage renal disease. Judicious is warranted as little as one dose can lead to colonic ulceration consistent with our case presentation.


American College of Gastroenterology (ACG) Annual Scientific Meeting, Orlando, FL, October 13-18, 2017.