Nambiar Sudheer, Pillai Unnikrishnan Kunjan, Devasahayam Joe, Oliver Tony, Karippot Asha
Pulmonary & Critical Care Medicine, Cancer Treatment Centers of America, Tulsa, OK, USA.
Nephrology, Indiana University, Muncie, IN, USA.
Case Rep Nephrol. 2018 Feb 28;2018:4708068. doi: 10.1155/2018/4708068. eCollection 2018.
End stage renal disease (ESRD) population account for 1.9 per patient year of hospital admissions annually. ESRD population are at increased risk of bleeding secondary to use of anticoagulation during hemodialysis and uremia induced platelet dysfunction. Gastrointestinal bleeding accounts for 3-7% of all deaths in ESRD population. Lower gastrointestinal bleeding refers to blood loss from a site in the gastrointestinal tract distal to the ligament of Treitz. It is usually suspected when a patient complains of hematochezia. It is different from patients presenting with hematemesis that suggests bleeding from upper gastrointestinal tract. Common causes of lower gastrointestinal bleed include diverticulosis, ischemia, hemorrhoids, neoplasia, angiodysplasia, and inflammatory bowel disease. ESRD patients are known to retain phosphate alone or in combination with calcium which has been associated with high mortality. Sevelamer is a phosphate binder used widely in ESRD population. The known side effects of sevelamer include metabolic acidosis, vomiting, nausea, diarrhea, dyspepsia, abdominal pain, constipation, flatulence, fecal impaction, and skin rash. We are reporting a unique case of a 56-year-old female with end stage renal disease on sevelamer hydrochloride who presented with gastrointestinal bleeding and underwent a right hemicolectomy found to have sevelamer-induced mucosal ulceration and crystal deposition in the colonic mucosa. This case report highlights the fact that, with widespread use of this medication in the patients with chronic kidney diseases, physicians should be aware of this underrecognized entity in the differential diagnosis of gastrointestinal bleed in ESRD patients.
终末期肾病（ESRD）患者每年的住院人次为每人年1.9次。ESRD患者因在血液透析期间使用抗凝剂以及尿毒症导致血小板功能障碍而有出血风险增加。胃肠道出血占ESRD患者所有死亡病例的3 - 7%。下消化道出血是指屈氏韧带远端胃肠道部位的失血。当患者主诉便血时通常会怀疑此病。它与表现为呕血（提示上消化道出血）的患者不同。下消化道出血的常见原因包括憩室病、缺血、痔疮、肿瘤、血管发育异常和炎症性肠病。已知ESRD患者单独或与钙结合潴留磷酸盐，这与高死亡率相关。司维拉姆是一种在ESRD患者中广泛使用的磷结合剂。司维拉姆已知的副作用包括代谢性酸中毒、呕吐、恶心、腹泻、消化不良、腹痛、便秘、肠胃胀气、粪便嵌塞和皮疹。我们报告了一例独特病例，一名56岁患有终末期肾病且正在服用盐酸司维拉姆的女性出现胃肠道出血，接受了右半结肠切除术，发现结肠黏膜有司维拉姆诱导的黏膜溃疡和晶体沉积。本病例报告强调了这样一个事实，即随着这种药物在慢性肾脏病患者中的广泛使用，医生在ESRD患者胃肠道出血的鉴别诊断中应意识到这种未被充分认识的情况。
