Calcium polystyrene sulfonate bezoar in the ileum: diagnosis and treatment with double-balloon endoscopy

Abstract

An 86-year-old man, admitted for transarterial chemoembolization of a hepatoma, developed fever and acute renal failure following the procedure. He was given antibiotic therapy and oral calcium polystyrene sulfonate (30 g daily) for hyperkalemia. After 1 week, the patient developed bilious vomiting with abdominal pain. An abdominal X-ray disclosed diffuse dilatation of the small bowel ([Fig. 1]) and computed tomography was suspicious for a bezoar in the ileum along with intestinal obstruction ([Fig. 2]). A surgeon was consulted but surgical therapy was declined due to the high surgical risk. The patient received conservative medical therapy but his intestinal obstruction failed to resolve. A decision was made to carry out retrograde enteroscopy to emove the bezoar. When the ileum was entered, we found a large, tubular-shaped, firm yellowish bezoar occupying the intestinal lumen ([Fig. 3] and [Video 1]). There were also some ileal ulcers. Irrigation with water and fragmentation using a snare helped mobilize the bezoar. Multiple small brownish granules were seen after the bezoar was fragmented ([Fig. 4]) and the aspirated fluid contained resin granules. Given the endoscopic findings and the drug history of the patient, he was diagnosed as having a calcium polystyrene sulfonate resin-associated bezoar. Despite the efforts to remove the bezoar, the patient died of multiple organ failure 1 month later.