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

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 (30g 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 decisionwasmade to carry out retrograde enteroscopy to emove the bezoar. When the ileum was entered, we found a large, tubular-shaped, firmyellowish bezoar occupying the intestinal lumen (●" Fig.3 and●" Video1). There were also some ileal ulcers. Irrigationwith water and fragmentation using a snare helpedmobilize thebezoar.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 calciumpolystyrene sulfonate resin-associatedbezoar. Despite the efforts to remove the bezoar, the patient died of multiple organ failure 1 month later. Calcium polystyrene sulfonate is an exchange resin used to treat hyperkalemia. A few cases of resin-related bezoars with intestinal obstruction have been reported [1–3]. Such bezoars most often form in critically ill infants [1–3] or in debilitated elderly patients with decreased bowel mobility and prolonged usage of the agent. The treatment of polystyrene sulfonate-related intestinal obstruction is surgery; only one case of non-surgical management has been reported [3]. The present case report documents the endoscopic findings related to resin-associated bezoar. In addition, we have found enteroscopy may be a useful tool in the treatment of intestinal obstruction resulting from the presence of such a bezoar. Endoscopy_UCTN_Code_TTT_1AP_2AD