Diffuse active ulceration with mucosal necrosis, hemorrhage and pseudomembrane formation Pseudomembranous colitis, Infectious colitis, Acute ischemic

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1 Clinical summary A 34-year-old man with intracerebal and intraventricular hemorrhages Emergency operation Past history : IgA nephropathy chronic renal failure hemodialysis Profuse hematochezia developed on the 11th day of admission Sigmoidoscopy

2 Diffuse active ulceration with mucosal necrosis, hemorrhage and pseudomembrane formation R/O Pseudomembranous colitis, Infectious colitis, Acute ischemic colitis, IBD (less likely)

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7 Lightly basophilic angulated crystal on HE stain Characteristic crystalline mosaic pattern on HE and D-Q stains Consistent with Kayexalate crystal

8 Review of medical note On the admission day Uremia, creatinemia and hyperkalemia Hemodialysis and oral Kalimate administration On the ninth day of admission Hyperkalemia (8.0 meq/l) and an EKG changes Kalimate Enemas (x2) (30 g of Kalimate in 200 ml of 20% DW) Oral Kalimate (15 g, t.i.d.) Two days later, profuse hematochezia developed C. difficile toxin assays (x4) Negative Stool culture - Negative

9 One week after the initial sigmoidoscopy Multiple scattered ulcers with slight improvement

10 Follow up biopsy

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13 Kayexalate Sodium polystyrene sulfonate, a potassium-binding resin, is used to treat hyperkalemia Administered orally, as an enema or by NG tube Should be given as a suspension in water or sorbitol, a hypertonic solution to avoid constipation, fecal impaction or bezoar formation Kalimate: calcium polystyrene sulfonate Manufacturer s guideline for Kalimate enema: A single dose (30 g) of Kalimate is suspended in 100 ml of water or 5% DW.

14 Kayexalate-associated GI necrosis Lillimoe et al. first reported in 1987 a series of five uremic patients with colonic necrosis who had received Kayexalate in sorbitol enemas All patients had concomitant multiple medical problems, especially uremia In experimental study, colonic necrosis was noted in all animals receiving enemas of sorbitol alone or Kayexalate in sorbitol, but not in ones receiving enemas without sorbitol.

15 Affected site: colon >> small intestine, esophagus, stomach, duodenum Pathology: Kayexalate crystals + Mucosal ulcers, pseudomembranes, edema, mucosal or transmural necrosis, bowel perforation and serositis DDx: Cholestyramine More basophilic, opaque without a mosaic pattern and rhomboid shape

16 Cholestyramine (Questran) crystals

17 Kayexalate-associated necrosis in upper and low GI tract Upper GI series (Am J Surg Pathol. 2001;25:637-44) - Total 11 patients: 7 esophagus, 6 stomach & 2 duodenum - No patient required surgical resection or died Low GI series (Am J Surg Pathol 1997;21:60 9) - 7 of 12 patients with colonic necrosis required surgery - Five of 7 patients who underwent colectomy died

18 Summary of clinicopathologic findings of patients with Kayexalateassociated colonic necrosis in the literature and the present case Authors No. of Pts Type of resin Type of suspension Route of administration Time interval Histopathologic findings Associated conditions Lillemoe et al. 5 Kayexalate Sorbitol Enema only (3) PO and enema (2) 3 days Transmural necrosis (5) CRF (3) CRF (1) Heart surgery (1) Rashid et al. 9 Kayexalate Sorbitol via NGT (1) PO (5) NS (3) 1~3 days Transmural necrosis (5) Mucosal ulceration (4) CRF (6) Alcoholic cirrhosis (1) Viral hepatitis (1) S/P RT for cancer (1) Kelsey et al. 1 Kayexalate Sorbitol PO 1 day Transmural necrosis CRF Rogers et al. 1 Kayexalate NS Enema 5 days Transmural necrosis CVA Scott et al. 1 Kayexalate Sorbitol Enema < 1 day Transmural necrosis Hypertension and CRF Cheng et al. 1 Kayexalate No sorbitol* PO 15 days Transmural necrosis Burn Present case 1 Kalimate 20% DW PO and enema 2 days Mucosal necrosis Hypertension and CRF

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