Volume 7, Issue 1 , Pages e1-e2, January 2009
Recurrent Obscure Gastrointestinal Bleeding in a Patient With Gastric Amyloid
Article Outline
A 68-year-old woman was evaluated for melena and anemia with a hemoglobin level of 7.5 g/dL. Eleven months previously, a colonoscopy was performed for iron-deficiency anemia and hematochezia, which showed erythema and friability of the rectal mucosa corresponding to reactive lymphoid aggregates on biopsy. A subsequent esophagogastroduodenoscopy performed 3 months later for dysphagia showed gastric mucosal erythema and chronic gastritis.
An upper endoscopy showed diffuse patchy granularity of the gastric folds with superimposed polypoid protrusions (Figure A). There was erythema and friability of the fundic mucosa suggestive of chronic gastritis, but no evidence of gross bleeding. Multiple biopsy specimens were taken, resulting in mild oozing of blood that was easily controlled with epinephrine injection. Differential diagnosis included lymphoma and amyloidosis. Routine hematoxylin phloxine saffron stain showed acellular pink material within thickened submucosal blood vessels (Figure B). Congo red staining showed deposition of a medium orange–colored material in submucosal blood vessel walls on light microscopy (Figure C). Birefringence microscopy revealed apple-green fluorescence highlighting the Congo red–stained areas (Figure D). The patient had no previous known diagnosis of rheumatoid arthritis, hematologic malignancy, connective tissue disorder, or evidence of systemic amyloidosis. The diagnosis was consistent with gastric amyloidosis.
Amyloidosis is an abnormal condition in which insoluble low-molecular-weight fibrillar protein subunits are deposited in extracellular tissue resulting in various clinical presentations depending on the type of protein and the amount and location of deposition. Systemic amyloidosis is more common than organ-specific amyloid and is associated with various chronic diseases such as rheumatoid arthritis, multiple myeloma, and chronic hemodialysis. In organ-specific amyloid the precursor protein subunit is thought to be synthesized and processed in close proximity to the amyloid deposition.1 Endoscopic findings of gastric amyloid can range from nonhealing ulcerations, mucosal erythema and friability, polypoid mucosal lesions, and isolated gastric masses. Rarely, however, there may be no endoscopic findings seen. Gastric amyloid is a rare condition in which amyloid infiltration can occur in the mucosal or submucosal layers of the gastric wall, and clinical manifestations include bleeding, poor appetite, epigastric discomfort, perforation, and subsequent gastric malignancy.2, 3
We present a rare case of obscure gastrointestinal bleeding secondary to isolated gastric amyloid deposition without evidence of systemic involvement. Endoscopic findings and a high clinical suspicion directed a histologic investigation for detecting localized gastric amyloid in this case. Gastric amyloid is often an incidental finding with a protean clinical presentation, as seen in this unusual case manifested by obscure gastrointestinal bleeding.
The authors thank Aman Ali, MD and Samuel Wahl, MD.
References
PII: S1542-3565(08)00904-X
doi:10.1016/j.cgh.2008.08.040
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
Volume 7, Issue 1 , Pages e1-e2, January 2009
