Acute Phlegmonous Gastritis Associated With Sodium Polystyrene Sulfonate (SPS) Administration

Abstract

FigureFigureAcute phlegmonous gastritis (APG) is a suppurative infection of the stomach. It is more frequently observed in immunocompromised hosts. Various microorganisms have been implicated including gram negative rods, gram positive cocci and anaerobes1. APG is most common in patients with compromised host defenses like AIDS and neutropenic populations9, rheumatologic disease10 and alcoholics12. Rarely, it follows disruption of the gastric mucosa such as gastric biopsy3 or India Ink marking2. It may also occur with synchronous mucosal lesions such as peptic ulcers15 or leiomyosarcoma14. Initial management includes broad-spectrum antimicrobials and hemodynamic support. However, definitive management generally involves resection or drainage of the affected area1. We present a case of APG associated with sodium polystyrene sulfonate (SPS) in an immunocompromised host. An elderly male undergoing treatment for lymphoma presented with renal failure and hyperkalemia. He was given SPS (marketed as Kayexalate) then developed melena. Esophogastroduodenoscopy (EGD) was performed and revealed purpuric, nodular, exudative and necrotic-appearing gastric mucosa (image 1). Biopsies showed severe acute phlegmonous gastritis with ulcerations, bacterial colonies and Kayexalate crystals (images 2-5). He was treated with meropenem, given bowel rest and diet was advanced gradually. Melena resolved and he was discharged in stable condition. APG is rare, occurring in those with compromised host defenses or injury to the gastric mucosa. In this setting, it appears that usually benign chemical and mechanical irritants can lead to suppurative inflammation with formation of abscess. In our patient, defective circulating lymphocytes and rituximab therapy likely resulted in diminished cell-mediated immunity, thereby rendering the mucosa susceptible. However, there was an even more direct association between Kayexalate administration and the development of APG. SPS with sorbitol is known historically for causing intestinal ischemia, and the use of sorbitol is no longer recommended. Injury to the upper gastrointestinal (GI) tract now occurs only in the minority of cases18. In our patient though, the use of SPS and presence of crystals on biopsy suggest an association between phlegmonous gastritis and SPS without sorbitol. While causality cannot be firmly established, our case provides a cautionary example of upper GI injury in association with SPS without sorbitol in an immunocompromised patient.Figure