A Rare Case of Hemorrhagic Gastritis Caused By Sevelamer-Induced Necrosis

Abstract

Case Report: A 64 year-old-male with history of ESRD, currently on hemodialysis presented with chief complain of nausea, bloody emesis and diffuse abdominal pain. His home medications were aspirin, hydralazine, gabapentin and sevelamer (4000 mg TID). He denied any history of NSAID use. On presentation, he was febrile, tachycardic and hypotensive. His labs were remarkable for Hb of 7.8, WBC of 10.3 and Cr of 7.7. The patient was resuscitated with normal saline and 1 unit of PRBC. CT abdomen showed pneumatosis with intramural air in the gastric fundus (Figure 1) Upper endoscopy revealed diffuse, severely friable mucosa in the gastric body, biopsy of which revealed pale yellow sevelamer crystals (Figure 2) deposited in the lamina propria of the body of the stomach. Sevelamer was discontinued and he was started on a low phosphate diet and a proton pump inhibitor. He was also advised to obtain a repeat EGD in 1 month.Figure 1: Pneumatosis with intramural air in posterior wall of the fundus of the stomach.Figure 2: Hematoxylin and eosin stain of ulcer bed with sevelamer crystals.Discussion: Sevelamer is anion exchange resin used to treat hyperphosphatemia in patients with ESRD. On hematoxylin and eosin stain, the crystals are 2-toned in appearance with bright pink accentuations on a rusty yellow background. There is very little literature on the mechanism of sevelamer mediated gastric mucosal injury. Sodium polysyterene sulfonate, a cation exchange resin used to treat hyperkalemia, is known to cause mucosal ischemia and ulceration by direct toxicity. Being an exchange resin, it is likely that sevelamer crystals cause mucosal injury by a similar mechanism of direct toxicity. To our knowledge, this is the first reported case of hemorrhagic gastritis due to sevelamer induced necrosis in the literature.