A Rare Case of Synchronous Severe Duodenal Ulcers and Acute Colitis in Sartan-Induced Enteropathy: A Case Report and Review of Literature

Abstract

Sartan induced sprue-like enteropathy (SIE) was initially reported as a side effect of chronic Olmesartan use in 2012 and is characterized by chronic diarrhoea and weight loss. The diagnosis is often difficult and requires ruling out of other causes of enteropathy including infectious gastroenteritis, autoimmune enteropathy and celiac disease. A 51 – year – old Caucasian male was admitted to our hospital because of chronic non-bloody diarrhoea associated with severe acute renal failure and electrolyte imbalances. His medical history was only positive for hypertension for which he was on Olmesartan Medoxomil and Lacidipine, both of which were discontinued due to hypotension at admittance. Stool cultures and search for C. Difficile toxin resulted negative, whilst a Colonscopy showed endoscopic and histological signs of aspecific acute colitis. After having responded to i.v. hydration with normalization of the renal function the patient was discharged home with the same medications he was on before admittance. His diarrhoea relapsed and he was readmitted shortly afterwards with acute renal failure and electrolyte imbalances; the anti-hypertensive medications were again discontinued. After having excluded all other causes of diarrohea, including celiac disease and HIV, Sartan – induced enteropathy (SIE) was suspected and then confirmed with an esophagogastroduodenoscopy which revealed a severe erosive duodenitis with multiple duodenal ulcers. The patient again responded to i.v. hydration with normalization of the renal function and Olmesartan was held also at discharge without further relapse of the symptoms. SIE is a rare cause of chronic diarrhoea, weight loss and possible severe renal failure. It could affect the whole gastrointestinal tract and in cases of unexplained non-bloody diarrhea, suspecting SIE is fundamental and should be considered in the differential diagnosis. Discontinuation of the drug is generally sufficient for symptom resolution: in suspected cases with a positive medical history for chronic angiotensin receptor blocker (ARB) use, stopping the drug ex-juvantibus should be undertaken. Further research on the immunopathological mechanisms and how to recognize patients at higher risk of developing this condition is deemed necessary.