University of Texas Health Science Center Houston, TX
Victor Garcia-Rodriguez, MD1, Zachari Grami, MD2, Aswathi Chandran, MD1, Sara I. Ali, MD1, Jessilyn Laney, MS1, Zhenjian Cai, MD, PhD1, Scott Larson, MD, PhD1; 1University of Texas Health Science Center, Houston, TX; 2The Ohio State University Wexner Medical Center, Houston, TX
Introduction: AEN is a rare cause of GI bleeding, endoscopically appears as circumferential black-appearing mucosa affecting almost universally the mid and distal esophagus. Risk factors include low flow states, malnutrition, alcoholism, and the presence of multiple comorbidities. Prolonged exposure to gastric secretions and direct contact with corrosive agents also induce mucosal ischemia. Here, we illustrate a case of AEN associated with sodium polystyrene sulfonate (SPS) use.
Methods: A 65-year-old female presented to the ED complaining of pain in her left arm. She had a history of hypertension, peripheral artery disease complicated by dry gangrene of both feet, end-stage renal disease on intermittent hemodialysis via LUE fistula, and NASH cirrhosis. Vital signs at presentation were stable. Physical exam revealed generalized cachexia, distended abdomen with a fluid wave, and black discoloration of both feet and fifth finger of her left hand. Laboratory revealed hemoglobin 9.6gr/dL, platelets 401.000/mcl, INR 1.2. Angiogram of her LUE showed radiographic steal of the fistula and severe stenosis of the radial and ulnar arteries. On her third day of admission, while awaiting surgical ligation of her LUE fistula, the patient developed melena. DRE revealed melanotic stools. Vital signs were stable during the episode and she had a drop in her Hgb. Upper endoscopy evidenced multiple ulcers in the upper third of the esophagus and ulcerated black mucosa in the mid and distal esophagus, no varices were seen (Fig.1-2) Biopsies were taken showing SPS resins concentrated within an acute necroinflammatory infiltrate (Fig.3) stains for CMV, HSV 1-2 and fungus were negative. The patient was treated conservatively with IV proton pump inhibitors and sucralfate. She underwent ligation of her LUE fistula and was discharged after eleven days, no recurrence of bleeding occurred at the time of discharge. Discussion: SPS has been associated with fatal gastrointestinal events including colonic necrosis and perforation. The upper gastrointestinal tract is rarely affected. In susceptible individuals, inoculation with SPS could provoke a severe inflammatory reaction with decreased prostaglandin levels leading to vasospasm and necrosis. Regardless of the etiology, AEN management consists of acid impression therapy and sucralfate. NG tube placement should be avoided. This case highlights an important consideration in the risk-benefit profile of SPS usage when alternative options for treating hyperkalemia exist.
Esophagogastroduedonoscopy revealing circumferential necrotic black mucosa in the mid esophagus.
Esophagogastroduedonoscopy revealing circumferential necrotic black mucosa in the distal esophagus.
Hematoxylin and eosin stain (x400) from esophageal mucosa revealing basophilic, “fish scale-like” sodium polystyrene sulfonate resins concentrated within an acute inflammatory exudate with necrosis.
Disclosures: Victor Garcia-Rodriguez indicated no relevant financial relationships. Zachari Grami indicated no relevant financial relationships. Aswathi Chandran indicated no relevant financial relationships. Sara Ali indicated no relevant financial relationships. Jessilyn Laney indicated no relevant financial relationships. Zhenjian Cai indicated no relevant financial relationships. Scott Larson indicated no relevant financial relationships.