Sorbitol, prostaglandins, and ulcerative colitis enemas

Rectal ulcer due to Kayexalate deposition - an unusual case

Sodium polystyrene sulfonate (PSP) or Kayexalate is a cation-exchange resin, widely used in the management of hyperkalaemia due to renal disease. A rare, yet potentially dangerous, adverse event related to sodium polystyrene sulfonate use is intestinal mucosal injury, especially in the colon. The injury to the gastrointestinal mucosa can range from mild and superficial to wall necrosis and bowel perforation. The mechanism that leads to mucosal damage remains unclear. However, it is believed that sorbitol, commonly given to counteract PSP's tendency to cause constipation, may play an important role in the development of gastrointestinal injury. Other potential risk factors are uraemia or end-stage renal disease, hemodynamic instability, solid organ transplantation, postoperative status and concomitant opioid administration. The authors present a case of diarrhoea and haematochezia after the administration of PSP without sorbitol, in a patient with hyperkalaemia due to acute kidney injury, in the absence of other risk factors. A colonoscopy was performed and revealed a rectal ulcer which histological findings were suggestive of mucosal injury due to Kayexalate deposition. This case supports the concept that this widely used drug can itself, without sorbitol, cause injury to the gastrointestinal wall. Even though this is a rare adverse effect, the widespread use of this medication may put a large population at risk.

Resin-Induced Colonic Pseudotumor: Rare Complication from Chronic Use of Potassium Binders in a Hemodialysis Patient

Potassium-binding resins are widely used in the treatment of hyperkalemia, mostly in the acute setting. Gastrointestinal adverse events, although reported, are not frequently seen due to its short course of use. This report describes a case involving an end-stage renal disease patient on hemodialysis who developed a colonic mass after being on sodium polystyrene sulfonate chronically for persistent hyperkalemia. Gastrointestinal symptoms developed late during the treatment rather than early as reported previously in the literature. This mass was mistaken for a carcinomatous lesion, which initiated an extensive work-up as well as hospitalization that nearly resulted in a subtotal colectomy.

Inflammatory Pseudotumor Containing Kayexalate Crystals: A Case Report and Review of the Literature

Kayexalate (sodium polystyrene sulfonate), a cation exchange resin often used to treat hyperkalemia, is known to produce gastrointestinal complications in a minority of patients. These complications range from mild gastrointestinal bleeding to perforation with acute abdomen. The typical histopathologic findings include mucosal ulceration, necrosis, and the presence of polygonal basophilic refractile crystals with a "fish scale" appearance. We present a unique case of Kayexalate crystals embedded in a perihepatic inflammatory pseudotumor, developing adjacent to a colostomy site in a 62-year-old woman following Kayexalate treatment. Microscopically, the lesion demonstrated a myofibroblastic proliferation rich in histiocytes and inflammation (lymphocytes, plasma cells, and eosinophils) as well as the presence of scattered typical Kayexalate crystals. This is the first report of extraintestinal Kayexalate identification in association with an inflammatory pseudotumor.

Colonic necrosis in a young patient receiving oral kayexalate in sorbitol: case report and literature review

Kayexalate (sodium polystyrene sulfonate) is a cation-exchange resin used to treat patients with hyperkalemia. Concomitant administration of kayexalate and sorbitol may induce gastrointestinal injury, which is potentially lethal. However, this well-documented complication is often underrecognized both clinically and pathologically. We propose a typical case along with colonoscopic photos and microscopic pictures. Additionally, we also present a review of the literature on this rare drug-induced side effect.

Intestinal necrosis due to sodium polystyrene sulfonate (Kayexalate) in sorbitol

BACKGROUND

Sodium polystyrene sulfonate (SPS, Kayexalate) has been implicated in the development of intestinal necrosis. Sorbitol, added as a cathartic agent, may be primarily responsible. Previous studies have documented bowel necrosis primarily in postoperative, dialysis, and transplant patients. We sought to identify additional clinical characteristics among patients with probable SPS-induced intestinal necrosis.

METHODS

Rhode Island Hospital surgical pathology records were reviewed to identify all gastrointestinal specimens reported as containing SPS crystals from December 1998 to June 2007. Patient demographics, medical comorbidities, and hospital courses of histologically verified cases of intestinal necrosis were extracted from the medical records.

RESULTS

Twenty-nine patients with reports of SPS crystals were identified. Nine cases were excluded as incidental findings with normal mucosa. Nine patients were excluded as their symptoms began before SPS administration or because an alternate etiology for bowel ischemia was identified. Eleven patients had confirmed intestinal necrosis and a temporal relationship with SPS administration suggestive of SPS-induced necrosis. Only 2 patients were postoperative, and only 4 had end-stage renal disease (ESRD). All patients had documented hyperkalemia, received oral SPS, and developed symptoms of intestinal injury between 3 hours and 11 days after SPS administration. Four patients died.

CONCLUSION

Intestinal ischemia is a recognized risk of SPS in sorbitol. Our series highlights that patients may be susceptible even in the absence of ESRD, surgical intervention, or significant comorbidity.

Colonic necrosis due to oral kayexalate in a critically-ill patient

Kayexalate (sodium polystyrene sulfonate in sorbitol) is commonly used for treatment of hyperkalemia. We describe the case of a critically ill patient who developed colonic necrosis after oral administration of kayexalate.

Upper gastrointestinal tract injury in patients receiving kayexalate (sodium polystyrene sulfonate) in sorbitol: clinical, endoscopic, and histopathologic findings

Kayexalate (sodium polystyrene sulfonate) in sorbitol has been demonstrated to cause colonic necrosis in a subset of uremic patients who are administered the cation exchange resin for treatment of hyperkalemia. Upper gastrointestinal damage associated with Kayexalate in sorbitol is reported far less frequently, and the clinicopathologic spectrum of disease in cases with upper gastrointestinal damage has not been investigated previously. The authors studied the clinical, endoscopic, and histologic features of 11 patients with Kayexalate crystals in biopsies from the esophagus (n = 7), stomach (n = 6), and duodenum (n = 2). The endoscopic appearance was markedly abnormal in all 11 patients. The effects of the medication closely mimicked other endoscopic and radiologic diagnoses in three cases, including esophageal carcinoma, Candidal esophagitis, and gastric bezoar. Histologic and/or endoscopic evidence of mucosal injury in the form of an ulcer or erosion was present in nine patients (82%). In four patients with mucosal injury, no other etiology apart from Kayexalate in sorbitol could be identified. In comparison with a cohort of patients with Kayexalate crystals in lower gastrointestinal specimens identified during the same period (11 patients) the frequency of associated mucosal damage was not significantly different (55%, p = 0.19), but no patient with upper gastrointestinal Kayexalate required surgical resection or died as a result of Kayexalate-induced mucosal injury. The results of this study provide evidence that Kayexalate in sorbitol can induce damage to the upper gastrointestinal tract. Recognition of Kayexalate crystals in histologic sections as a marker for sorbitol-induced mucosal damage may aid in establishing the correct diagnosis for clinically or endoscopically misleading lesions.

Combined gastric and ileocecal toxicity (serpiginous ulcers) after oral kayexalate in sorbital therapy

Kayexalate (Roxane Labs, Columbus, OH) in sorbitol is commonly administered by the oral and rectal route for the treatment of hyperkalemia in patients with renal failure. It is believed to have minimal toxicity because it functions as a cation exchanger and is not absorbed. We herein report on a patient who developed identical serpiginous ulcers in the stomach and the terminal ileum after the use of Kayexalate. We believe that this drug could have significant gastrointestinal toxicity in specific patient groups and suggest tentative guidelines, both for the identification of such patients and for the safer use of Kayexalate in these circumstances.

Intestinal necrosis associated with postoperative orally administered sodium polystyrene sulfonate in sorbitol

We estimated the incidence of intestinal necrosis in 752 hospitalized patients who had received sodium polystyrene sulfonate (SPS). Of these 752 patients, 117 were exposed within 1 week of surgery. Two cases of intestinal necrosis were discovered, both in patients who had received orally administered SPS in sorbitol within 1 week of surgery. Based on these two cases, the postoperative incidence of intestinal necrosis associated with SPS was 1.8%. For comparative purposes, we identified 862 patients who had undergone hemodialysis, renal transplantation, or cardiac transplantation, but did not receive SPS. No cases of idiopathic intestinal necrosis were found in this second group (P = 0.014). These data suggest that SPS in sorbitol-associated intestinal complications may be a relatively common occurrence in postoperatively exposed patients.