Mayo School of Graduate Medical Education Rochester, MN, United States
Chineze N. Akusoba, 1, Jennifer Gile, 1, Christopher Dinh, 1, Eric Chen, 2 1Mayo School of Graduate Medical Education, Rochester, MN; 2Mayo Clinic, Rochester, MN
Introduction: Gastrointestinal involvement is common in amyloid light chain (AL) amyloidosis, however gastrointestinal hemorrhage secondary to amyloidosis is rare. Both upper and lower gastrointestinal hemorrhage have been reported in the literature. Often, diffuse involvement of the gastrointestinal tract is more common than one discrete lesion, making endoscopic or surgical treatment challenging.
Case Description/Methods: A 70-year-old man with a known history of AL amyloidosis and acquired factor X deficiency presented to the ED with melena and hematochezia. Physical examination was notable for blood pressure of 68/44 mm Hg and a pulse of 114 beats/min. His abdomen was soft, non-distended and diffusely tender to palpation. Rectal exam revealed bright red blood. Laboratory evaluation revealed hemoglobin 6.3 g/dL, platelets 127 x109/L, blood urea nitrogen (BUN) 46 mg/dL, creatinine 2.1 mg/dL and INR 1.9. The patient received 3 units of packed red blood cells, 2 units of fresh frozen plasma (FFP) and 2 L of crystalloid for resuscitation from hemorrhagic shock. He underwent emergent EGD which revealed mucosal friability throughout the stomach and duodenum but did not show any active bleeding. The following day the patient underwent a colonoscopy which revealed multiple very large rectal ulcers with adherent clot. Histologic staining with Congo red stain revealed positively staining deposits in the vasculature of the ulcer bed that exhibited apple-green birefringence under polarized light consistent with amyloidosis. Given diffuse involvement and no intervenable site, no endoscopic intervention was performed. Hematology recommended use of FFP or recombinant factor X to correct coagulation abnormalities if the patient had ongoing bleeding. The patient’s hemoglobin remained stable and he did not have recurrent bleeding during the hospitalization.
Discussion: Amyloidosis can be associated with life-threatening gastrointestinal hemorrhage. In patients with AL amyloidosis, acquired hemostatic abnormalities, including coagulation deficiencies, hyperfibrinolysis, and platelet dysfunction, are considered the primary pathogenic factors. Amyloid angiopathy with increased fragility of blood vessels and impaired vasoconstriction may also promote bleeding. Early endoscopic intervention and tissue biopsy is indicated in patients with clinical suspicion for amyloidosis.
Disclosures: Chineze Akusoba indicated no relevant financial relationships. Jennifer Gile indicated no relevant financial relationships. Christopher Dinh indicated no relevant financial relationships. Eric Chen indicated no relevant financial relationships.
Chineze N. Akusoba, 1, Jennifer Gile, 1, Christopher Dinh, 1, Eric Chen, 2. P2603 - Amyloidosis: An Unusual Case of Gastrointestinal Bleeding, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.