The Carcinomatosis Peritonei with Primary from Stomach Carcinoma of stomach with function gastric outlet obstruction
Abstract
Abstract
We present the case of 55year old male who presented with low SAAG high protein ascites and had cytology tested negative for malignant cells. Omental biopsy reported metastatic adenocarcinoma. His PET-CT showed asymmetrical mural thickening involving antrum and pylorus of the stomach with increased FDG uptake. Upper gastrointestinal endoscopy showed that the antral wall seemed pliable on probing with biopsy forceps, although no peristalsis wave was seen passing through with absence of normal mucosal pattern in antrum biopsy was showed chronic gastritis. Biopsy also had rhomboid plate-like crystals with scaling in the milieu of the gastric mucosa. Retrospective history revealed that the patient had taken sodium polystyrene sulfonate for hyperkalemia, 6days before the biopsy. Most of the case reports are on intestinal in the setting of functional gastric outlet obstruction there was the earlier deposition of sodium polystyrene sulfonate crystals in the gastric mucosa. Earlier identification in biopsy prevented consequences of crystal deposition such as erosion, pneumatosis, and perforation.
Abbrevation:
Kayexalate; Sodium polystyrene sulfonate; Adenocarcinoma
Introduction:
Kayexalate, or sodium polystyrene sulfonate, is an ionexchange resin used to treat hyperkalemia. It is typically given to patients with chronic kidney disease (CKD) who have a mildly elevated potassium level on a regular basis(1,2). To treat constipation and prevent faecal impaction, SPS is occasionally used with sorbitol, an osmotic laxative(1–3).
Kayexalate has been linked to several occurrences of gastrointestinal necrosis, ulceration, and perforation, mostly in the large and small intestine(1,4–6). Only few cases where gastric involvement had occurred and documented. In this case report SPS crystal deposition in gastric mucosa is an incidental finding in patient with carcinoma stomach who has functional gastric outlet obstruction and hyperkalemia received SPS for only 6days.
Case report
A 55 year male who was referred to our hospital as a case of decompensated chronic liver disease with grade III ascites upon evaluation of ascitic fluid had total cells of 255 with polymorphs 13.2 and lymphocytes 86.8 with low SAAG high protein with ADA of 22.4 and had gene-Xpert, KOH mount, gram stain negative. Culture and sensitivity showed no growth. Ascitic fluid malignant cytology three consecutive samples were negative. Liquid based cytology was negative for malignant cells. Cross sectional imaging computerised tomography abdomen showed hepatomegaly with omental thickening & features of peritonitis- likely tubercular etiology and hence omental biopsy done and showed metastatic adenocarcinoma. While awaiting for immunohistochemistry he underwent PETCT which was showing asymmetrical circumferential mural thickening noted involving the antrum and reaching upto the pylorus of stomach, length of involvement approximately 3cm, maximum thickness approximately 1.3cm, and showing increased FDG uptake. FDG avid extensive omental thickening and stranding and areas of FDG avid nodular peritoneal thickening were seen. He underwent upper gastrointestinal endoscopy which Functional gastric obstruction with dilated stomach with loss of normal antral mucosal pattern, for which he underwent biopsy of antrum which was showing features of chronic gastritis but he had rhomboid crystal with fish scaling suggestive of kayexalate crystals. His history when reviewed had sodium polystyrene sulfonate intake for 6days for hyperkalemia. His immunohistochemistry came positive for CK 7 ,CK 19, MUC5AC positive but CK 20 negative. Diagnosis of carcinomatosis peritonei with primary from stomach was made.He was referred to medical oncology and was initiated on chemotherapy.
Figure 1.The antral mucosa showed normal antral mucosa at most places, but there were areas with pale
mucosa with loss of normal mucosal surface pattern; small scatterred ulcerations were also seen.
Figure 3: Rhomboid crystals with fish scaling compatible with kayexalate crystals.
DISCUSSION
Several incidences of gastrointestinal injuries caused by Kayexalate have been described in the past. A systematic evaluation of 50 cases of SPS-related gastrointestinal events, most of which presented as transmural colonic necrosis, was published by Harel et al(1). After administering Kayexalate enemas and Kayexalate with sorbitol solutions via nasogastric tube, Gardiner documented patchy hemorrhagic erosions of the stomach, ileum, and colon (2). Gastric and ileal serpiginous ulcers were treated with Kayexalate in sorbitol in a research by Roy Chaudhury et al(7). In a patient with severe kidney injury, Usta et al.(8) recently described a case of emphysematous gastritis and necrosis caused by oral intake of Kayexalate in sorbitol. To the best of our knowledge We present you a case of functional gastric outlet obstruction who had hyperkalemia for which had taken sodium polystyrene sulfonate for only 6days and presented with kayexalate crystal deposition in the stomach.
Table 1: Case reports of kayexalate induced gastric injury
Author
Age (Yrs)
Sex(M/F)
Site
Tissue reaction
Consequence
Background
Neethi Dasu et al(9)
52y
Male
Stomach and intestine
Endoscopy:Gastric mucosal injury without necrosis
CT: Gas in portal vein and wall of stomach
Gastric necrosis
Hypertension, chronic diarrhea, hyperlipidemia, and Type 2 Diabetes
Jennifer et al(10)
23y
Male
Stomach
Endoscopy
generalized mucosal erythema with intramucosal
bleeding in the gastric fundus and corpus along the greater
curvature of the stomach
Gastric necrosis
T cell- ALL WITH Stem cell transplant on cyclosporine and methotrexate
Roy Hajjar et al(11)
48y
Male
Stomach
Endoscopy: Blood in upper GI tract with large clot in the stomach
Xray: Pneumoperitoneum
Gastric perforation
Hypertension, dyslipidemia, CKD, and a Double lung transplant chronic rejection ON steroids.