Endoscopic and biopsy findings of the upper digestive tract in patients with amyloidosis

An unusual phenotype of hereditary AApoAI amyloidosis caused by a novel Asp20Tyr substitution is linked to pH-dependent aggregation of apolipoprotein A-I

Apolipoprotein A-I (apoA-I) plays beneficial roles as the major structural and functional protein on plasma high-density lipoproteins (HDL). However, APOA1 gene mutations can cause protein misfolding and pathologic amyloid deposition in various organs in human hereditary AApoAI amyloidosis, a potentially lethal systemic disease. We report esophageal and duodenal AApoAI amyloidosis in a 56-year-old patient with Barrett's esophagus, a condition involving chronic acid reflux. Amyloid deposits contained full-length apoA-I featuring a novel D20Y mutation identified by gene sequencing and protein mass spectrometry. Genetic analysis of asymptomatic family members revealed autosomal dominant inheritance. Fibril formation by the full-length variant apoA-I rather than its fragments and the location of the mutation in a conserved amyloid-prone N-terminal segment were highly unusual for hereditary AApoA-I amyloidosis. Structural and stability studies of the recombinant D20Y and wild-type apoA-I showed small but significant mutation-induced structural perturbations in the native lipid-free protein at pH 7.4. Major destabilization and aggregation of the variant protein were observed at pH 4.0. We propose that acidic conditions in Barrett's esophagus promoted protein misfolding and amyloid formation by the D20Y variant. These findings expand our understanding of the clinical features and molecular basis of AApoAI amyloidosis and suggest clinical strategies.

Endoscopic and pathological characteristics of gastrointestinal amyloidosis: a retrospective analysis

BACKGROUND

Gastrointestinal amyloidosis (GIA) is a rare manifestation of amyloidosis, characterized by amyloid fibril deposition in the gastrointestinal tract, leading to a range of clinical symptoms. Early diagnosis is challenging due to the nonspecific nature of endoscopic and clinical findings.

OBJECTIVE

To analyze the clinical, endoscopic, and pathological characteristics of GIA and identify potential diagnostic markers for earlier detection.

METHODS

A retrospective study was conducted on 36 patients diagnosed with GIA based on histopathological findings, including Congo Red staining. Clinical, endoscopic, and pathological data were analyzed to identify correlations between lesion morphology, clinical symptoms, and amyloid deposition.

RESULTS

The cohort consisted of 22 males (61.1%) and 14 females (38.9%), with a mean age of 61.7 years. Endoscopic findings were diverse, with elevated lesions (57.1%) most common in the esophagus, stomach, and small intestine, and white patches (66.7%) prevalent in the duodenum. Histopathological analysis confirmed amyloid deposits in 62.8% of biopsy specimens. The small intestine exhibited the highest detection rate (100%), while the colorectum had the lowest (37.5%). Patients with elevated lesions may be asymptomatic, and among those with symptoms, abdominal pain is most common. Flat lesions are primarily associated with multiple symptoms, with abdominal discomfort, pain, distension, and acid reflux being the most frequent. The infiltration depth varied across different gastrointestinal tract segments, with the mucosal layer predominantly affected in the esophagus and stomach, whereas the submucosal layer more significantly involved in the duodenum and colon.

CONCLUSION

Gastrointestinal amyloidosis presents with a wide range of clinical symptoms and endoscopic manifestations. Histopathological diagnosis through standardized biopsy is crucial, and attention should be given to the depth of tissue sampling, as it may play a significant role in reducing misdiagnosis.

Digestive Amyloidosis Trends: Clinical, Pathological, and Imaging Characteristics

Amyloidosis is a group of diseases characterized by the extracellular deposition of abnormally folded, insoluble proteins that lead to organ dysfunction. While it commonly affects the cardiovascular system, gastrointestinal (GI) tract involvement is undetermined. Recent research has focused on understanding the pathophysiology, diagnostic challenges, and therapeutic approaches to GI amyloidosis, particularly in systemic amyloid light-chain (AL) and amyloid A (AA) forms. GI manifestations can include motility disorders, bleeding, and, in severe cases, bowel obstruction. This review highlights the importance of the early recognition of digestive symptoms and associated imagistic findings in GI amyloidosis by analyzing the research that included clinical, pathological, and endoscopic approaches to amyloidosis. A systematic search of the PubMed and Scopus databases identified 19 relevant studies. Our findings showed that amyloid deposits commonly affect the entire GI tract, with AL amyloidosis being the most predominant form. Endoscopic evaluations and biopsy remain key diagnostic tools, with Congo Red staining and mass spectrometry being used to confirm amyloid type. Although progress has been made in diagnosis, the absence of targeted therapies and the indistinct nature of GI symptoms continue to be challenging.

Systemic Amyloid A Protein Amyloidosis With Gastrointestinal Involvement

Systemic amyloidosis is a multiorgan deposition of misfolded amyloid protein fibrils. The systemic amyloid A protein (AA) amyloidosis type predominantly involves the kidney and is mostly an under-recognized complication among persons who inject drugs. Gastrointestinal involvement in systemic AA amyloidosis that is associated with illicit drug use is uncommon. In this report, we present a case of a 40-year-old man with history of injection drug use, recurrent skin and soft-tissue infection, and renal AA amyloidosis that presented with painless bloody bowel movement, which initially resolved with conservative management. Upon further evaluation, the patient was found to have empyema that required antibiotic therapy and bilateral pleural drain. His hospital course was further complicated by multiple episodes of hematochezia requiring gastrointestinal consultation. Subsequent gastrointestinal biopsy revealed amyloid deposit.

Characterization of Amyloidosis in the Gastrointestinal Tract With an Emphasis on Histologically Distinct Interstitial Patterns of Deposition and Misinterpretations

Amyloidosis can involve the gastrointestinal (GI) tract, and deposition can present with varied histologic patterns that make recognition challenging. This retrospective observational study aimed to characterize the deposition patterns in the GI tract and evaluate key quality metrics, including discrepant cases, to improve recognition and provide insight for accurate diagnosis. Sixty-two patients (195 biopsies) with amyloid involvement of the luminal tract were reviewed. Amyloid subtyping by mass spectrophotometry was available for 59 patients. Immunoglobulin light chain (AL) was the most commonly identified subtype (60%), followed by serum amyloid A (AA; 19%) and transthyretin (ATTR; 16%). 150/195 biopsies (77%) were positive for amyloid deposition, with an average of 2.4 positive biopsies per every 3.1 taken per patient. The sites with the highest yield were duodenum (37/37, 100%) and colon (63/74, 85%). Gastric biopsies were most likely to involve the lamina propria (41/45, 91%, P < 0.001), with the background mucosa showing reactive epithelial changes in almost half of the biopsies (20/45, 44%). Several distinct histologic patterns of interstitial deposition were identified, including muscularis mucosae deposition (n = 40, 27% of positive biopsies), peri-Brunner gland (n = 6, 17% of duodenal biopsies), mass-forming (n = 4, 2.7% of positive biopsies, including 3 suspected cases with localized involvement), collagenous colitis-like (n = 3, 4.8% of positive colonic biopsies), and globular (n = 19, 12.7% of positive biopsies). Congo Red was ordered in 81% of cases in which it was requested clinically, with a positivity rate of 30%. Of the 34 cases in which an amyloid workup was requested (but Congo Red was not performed), 14 were positive on reevaluation. Several missed cases had deposition in multiple biopsies, and almost half were missed by subspecialist GI pathologists. Nine misinterpretations were from the stomach, with seven initially diagnosed as chemical or reactive gastropathy. Additional discrepant cases were identified from the duodenum (n = 2) and colon (n = 3), with the vascular-only deposition pattern (n = 3), muscularis mucosae-only deposition (n = 3), and globular pattern (n = 1) identified. Given the challenges of identifying amyloid on hematoxylin and eosin staining, Congo Red ordering percentage should be 100% in clinically suspicious cases unless deposition is definitively seen on hematoxylin and eosin staining.

Systemic AL amyloidosis with multiple submucosal hematomas of the colon: a case report and literature review

Amyloid light-chain (AL) amyloidosis rarely causes colorectal submucosal hematoma. A 76-year-old man presented with a complaint of bloody stool. An initial colonoscopy revealed ulcerative lesions in the descending colon, leading to a diagnosis of ischemic colitis. One month later, he presented with cardiac failure, suspected cardiac amyloidosis, and underwent a second colonoscopy. Although it revealed multiple ulcerative lesions from the ascending to transverse colon, biopsy samples did not confirm amyloid deposition. He underwent a third colonoscopy 3 weeks later due to recurrent bloody stool. It showed multiple submucosal hematomas from the ascending to descending colon concomitant with ulcerative lesions in the descending colon and multiple elevated lesions in the sigmoid colon. Biopsy samples confirmed amyloid deposition. Using a systemic search, multiple myeloma with AL amyloidosis was diagnosed. Colorectal submucosal or intramural hematomas are conditions usually encountered in trauma, antithrombotic use, or coagulation disorders. Based on our review of the literatures, we identified several differences between colorectal intramural hematoma caused by amyloidosis and those caused by other etiologies. We believe that amyloidosis should be considered when relatively small and multiple colorectal hematomas, not restricted to the sigmoid colon, and with concomitant findings of erosions and ulcers, are observed.

Gastroduodenal Involvement in AL Amyloidosis: Case Report and Literature Review

Gastrointestinal amyloidosis is a rare condition commonly found in the setting of systemic AL amyloidosis. Amyloid can deposit throughout the gastrointestinal tract and the resulting symptoms vary depending on the site of deposition. Gastrointestinal (GI) manifestations can range from weight loss or abdominal pain, to more serious complications like gastrointestinal bleeding, malabsorption, dysmotility, and obstruction. This case describes a patient with known history of IgG lambda AL amyloidosis, presenting with epigastric pain and unintentional weight loss found to have gastroduodenal amyloidosis. The definitive diagnosis of GI amyloidosis requires endoscopic biopsy with Congo red staining and visualization under polarized light microscopy. There are currently no specific guidelines for the management of GI amyloidosis. Generally, the goal is to treat the underlying cause of the amyloidosis along with symptom management. Our patient is being treated with cyclophosphamide, bortezomib, and dexamethasone (CyBorD) and started on hemodialysis due to progression of renal disease.

Gastrointestinal amyloidosis: an often unexpected finding with systemic implications

The gastrointestinal (GI) tract is a common site of amyloidosis, but the incidence, clinicopathologic features, and systemic implications of different types of GI amyloidosis are not well understood. GI amyloid specimens (N = 2511) typed using a proteomics-based method between 2008 and 2021 were identified. Clinical and morphologic features were reviewed in a subset of cases. Twelve amyloid types were identified, including AL (77.9%), ATTR (11.3%), AA (6.6%), AH (1.1%), AApoAIV (1.1%), AEFEMP1 (0.7%), ALys (0.4%), AApoAI (0.4%), ALECT2 (0.2%), Aβ2M (0.1%), AGel (0.1%), and AFib (<0.1%). Amino acid abnormalities indicative of known amyloidogenic mutations were detected in 24.4% ATTR cases. AL, ATTR, and AA types all commonly involved submucosal vessels. They also showed some characteristic patterns of involvement of more superficial anatomic compartments, although there was significant overlap. Common indications for biopsy were diarrhea, GI bleed, abdominal pain, or weight loss. Amyloidosis was usually an unexpected finding, but most AL and ATTR patients were ultimately found to have cardiac involvement (83.5% of AL; 100% of ATTR). Although most GI amyloid is of AL type, over 10% are ATTR, over 5% are AA, and twelve different types were identified in total. GI amyloid is often unexpected but usually signals systemic amyloidosis, thus there should be a low threshold to perform biopsy with Congo red stain in patients with unexplained GI symptoms. Clinical and histologic features are nonspecific, and typing should be performed via a robust method such as proteomics as treatment hinges on correctly identifying the amyloid type.

Gastrointestinal (GI) Amyloidosis Presenting As Chronic Diarrhea: A Diagnostic Dilemma

This case report describes a 63-year-old male patient with a four-year history of chronic diarrhea. Extensive diagnostic investigations failed to reveal a cause. Subsequent upper and lower gastrointestinal (GI) endoscopic procedures revealed the presence of amyloidosis in the GI tract. The patient was referred for further evaluation, but unfortunately, he presented with hypotension and shock, and ultimately succumbed to systemic amyloidosis involving multiple organs. GI amyloidosis, although rare, should be considered in patients presenting with chronic diarrhea, unexplained weight loss, or GI bleeding. Early recognition and appropriate management are crucial for optimizing patient outcomes. Healthcare providers should maintain a high index of suspicion for GI amyloidosis to ensure timely intervention and improve patient care.

Pseudotumoral Amyloidosis Presentation With Upper Digestive Bleeding

Amyloidosis is a condition related to the extracellular deposition of abnormal fibrillar proteins. Gastric involvement may present as a systemic or localized form of the disease. The endoscopic presentation can vary from nodular, ulcerated, or infiltrative lesions. Clinical manifestations are nonspecific, including hyporexia, nausea, vomiting, weight loss, epigastralgia, and abdominal discomfort. Thus, amyloidosis can clinically and endoscopically mimic other diseases, such as neoplasms, syphilis, tuberculosis, and Crohn's disease, requiring a high suspicion. When it manifests with gastrointestinal bleeding, it most commonly occurs as intermittent melena. This report aims to present an unusual case of a patient with upper gastrointestinal bleeding exteriorized through melena secondary to amyloidosis with gastric involvement.

A Rare Case of Gastrointestinal Amyloidosis Due to Monoclonal Gammopathy of Undetermined Significance

Amyloidosis of the gastrointestinal (GI) tract is caused by the deposition of fibrils made of serum proteins into extracellular spaces. It is an uncommon disease with a poor prognosis, requiring prompt diagnosis and treatment. Treatment for amyloid light chain (AL)-type amyloidosis involves supportive care as well as addressing any underlying plasma cell dyscrasias. We present the case of a 64-year-old female diagnosed with AL-type GI amyloidosis with associated monoclonal gammopathy of undetermined significance. Unfortunately, the treatment was initiated nine months after the initial presentation, and she died one month later. Awareness of GI amyloidosis may allow for faster diagnosis and treatment in future patients.

Pathophysiology, Functional Assessment and Prognostic Implications of Nutritional Disorders in Systemic Amyloidosis

Gastrointestinal involvement is a common clinical feature of patients with systemic amyloidosis. This condition is responsible for invalidating gastrointestinal symptoms, a significant macro and micronutrient deficit, and is a marker of disease severity. Gastrointestinal involvement should be actively sought in patients with systemic amyloidosis, while its diagnosis is challenging in patients with isolated gastrointestinal symptoms. The nutritional status in systemic amyloidosis plays an essential role in the clinical course and is considered a significant prognostic factor. However, the definition of nutritional status is still challenging due to the lack of internationally accepted thresholds for anthropometric and biochemical variables, especially in specific populations such as those with systemic amyloidosis. This review aims to elucidate the fundamental steps for nutritional assessment by using clinical and instrumental tools for better prognostic stratification and patient management regarding quality of life and outcomes.

Primary Localized Small Bowel Amyloidosis: A Rare Cause of Diarrhea Detected by Balloon-Assisted Enteroscopy

Gastrointestinal involvement occurs in approximately 4% of cases of systemic amyloidosis and may be associated with heterogeneous and nonspecific clinical manifestations and endoscopic findings, which poses important diagnostic challenges. A 76-year-old female with previous medical history of breast cancer, hypertension, dyslipidemia, asthma, and depression presented to emergency department with a 1-month history of diarrhea, abdominal pain, anorexia, asthenia, and weight loss. Physical examination revealed dehydration and abdominal tenderness. Stool microbiologic studies, Clostridium difficile toxin, fecal leukocyte count, stool fat, and celiac serology were all negative. Remarkably, an axillary lymphadenopathy was also noted and its investigation revealed multiple myeloma, which raised suspicion for gastrointestinal amyloidosis. However, upper digestive endoscopy and colonoscopy did not reveal abnormalities and both gastric and colon biopsies were negative for amyloid, as was abdominal fat biopsy. As the patient also presented hypoproteinemia and hypoalbuminemia suggestive of protein-losing enteropathy, videocapsule endoscopy was performed where petechiae, villous atrophy, and fissures were seen along jejunal mucosa. These findings were confirmed with double-balloon enteroscopy and jejunal biopsies revealed extensive deposition of an amorphous hyaline material in lamina propria and muscularis mucosae that exhibited apple-green birefringence under polarized light after Congo red staining, consistent with localized small bowel amyloidosis secondary to multiple myeloma. Chemotherapy was started, but she would die after 3 weeks. This case illustrates the role of balloon-assisted enteroscopy in diagnosis of localized small bowel amyloidosis with jejunal involvement.

Clinical and endoscopic findings in gastrointestinal amyloidosis: a single-center experience

Gastrointestinal involvement occurs in approximately 4% of cases of systemic amyloidosis. The most common site of amyloid deposition is small bowel, followed by stomach, colorectum and esophagus. Although rare, gastrointestinal amyloidosis may be associated with severe complications including gastrointestinal bleeding or perforation and may be mistaken for malignancy.

A Rare Case of Gastrointestinal Amyloidosis Presenting as Dysphagia

A 74-year-old male with an unintentional 20-pound weight loss over the past year presented with new-onset dysphagia to solid foods. Esophagogastroduodenoscopy showed a subtle stricture with ill-defined scar tissue-like findings in the distal esophagus and erosions in the antrum of the stomach without masses. Pathologic findings showed the presence of amyloidosis involving the proximal and distal esophagus, as well as gastric mucosa with chronic inflammation and reactive epithelial changes. We present a rare case of dysphagia as the initial presentation of gastrointestinal amyloidosis.

Gastric amyloidosis presenting as acute upper gastrointestinal bleeding: a case report

Background

Amyloidosis is characterized by extracellular tissue deposition of fibrils, composed of insoluble low-molecular-weight protein subunits. The type, location, and extent of fibril deposition generates variable clinical manifestations. Gastrointestinal (GI) bleeding due to amyloid deposition is infrequent. Previous literature describes upper GI bleeding (UGIB) in patients with known amyloid disease. Here, we describe a case of recurrent UGIB that ultimately led to a diagnosis of GI amyloidosis and multiple myeloma in a patient with no history of either.

Case presentation

A 76-year-old male presented to the emergency department with frank hematemesis, melena, and a decreased level of consciousness. Management required intensive care unit (ICU) admission with transfusion, intubation, and hemodynamic support. Upper endoscopy revealed gastritis with erosions and nodularity in the gastric cardia and antrum. Hemostasis of a suspected bleeding fundic varix could not be achieved. Subsequently, the patient underwent computerized tomography (CT) angiography and an interventional radiologist completed embolization of the left gastric artery to address potentially life-threatening bleeding. Complications included development of bilateral pleural effusions and subsegmental pulmonary emboli. Pleural fluid was negative for malignancy. He was transferred to a peripheral hospital for continued care and rehabilitation. Unfortunately, he began re-bleeding and was transferred back to our tertiary center, requiring re-admission to the ICU and repeat endoscopy. Repeat biopsy of the gastric cardial nodularity was reported as active chronic gastritis and ulceration. However, based on the unusual endoscopic appearance, clinical suspicion for malignancy remained high. He exhibited symptoms of congestive heart failure following standard resuscitation. Transthoracic echocardiogram (TTE) demonstrated a reduced ejection fraction of 35–40% and a strain pattern with apical sparing. Following discussions between the treating gastroenterologist, consulting cardiologist, and pathologist, Congo Red staining was performed, revealing submucosal amyloid deposits. Hematology was consulted and investigations led to diagnosis of multiple myeloma (MM) and immunoglobulin light-chain (AL) amyloidosis. The patient was treated for MM for four months prior to cessation of therapy due to functional and cognitive decline.

Conclusions

GI amyloidosis can present with various non-specific clinical symptoms and endoscopic findings, rendering diagnosis a challenge. This case illustrates GI amyloidosis as a potential—albeit rare—etiology of UGIB.

Suggestive Diagnostic Process in a Case of Multiple Myeloma with Gastrointestinal Immunoglobulin Light-Chain Amyloidosis Accompanied by Protein-Losing Enteropathy

Multiple myeloma is a type of plasma cell neoplasm that produces monoclonal immunoglobulin. Multiple myeloma is known to cause immunoglobulin light-chain (AL) amyloidosis, which frequently involves the kidney and heart. Bone pain or fractures caused by osteolytic lesions and physical disorders related to renal or cardiac AL amyloidosis are major initial symptoms in multiple myeloma. Multiple myeloma diagnosed from the gastrointestinal symptoms is rare. We report a case of an 80-year-old man with multiple myeloma accompanied by gastrointestinal AL amyloidosis and secondary protein-losing enteropathy. The diagnostic process was suggestive, in that diarrhea and refractory leg edema related to protein-losing enteropathy were the primary symptoms and the trigger for making a sequential diagnosis of gastrointestinal AL amyloidosis and underlying multiple myeloma. This case is highly suggestive, in that multiple myeloma with gastrointestinal AL amyloidosis should be considered one of the background diseases of protein-losing enteropathy.

A Rare Case of Localized Esophageal Amyloidosis

A 72-year-old man without any symptoms was referred to our hospital. Esophagogastroduodenoscopy revealed an elevated esophageal lesion that was covered with normal mucosa. The examination of biopsy specimens from the lesion revealed amyloid light-chain (AL) (λ) type amyloid deposits, but there were no amyloid deposits elsewhere in the gastrointestinal tract. Further examinations did not indicate systemic amyloidosis. Thus, this case was diagnosed as a localized esophageal amyloidosis. As the clinical outcome of localized amyloidosis is favorable, this case was scheduled for close follow-up. Localized amyloidosis should be considered in the differential diagnosis of esophageal submucosal tumors.

Systemic Immunoglobulin Light Chain Amyloidosis Involving the Large Intestine

Amyloidosis is characterized by extracellular tissue deposition of fibrils resulting in disruption of tissue structure and function. Gastrointestinal amyloidosis commonly results from chronic inflammatory disorders (amyloid A amyloidosis) and is less commonly seen in immunoglobulin light chain amyloidosis. We present a rare case of a 50-year-old man with a history of immunoglobulin light chain amyloidosis who presented with abdominal pain, blood in stool, diarrhea, and weight loss. Colonoscopy and biopsies revealed amyloid deposits in the colon. The patient subsequently was referred to colorectal surgery for evaluation of total colectomy with further plans for chemotherapy and subsequent hematopoietic cell transplantation.

Autopsy findings in a patient with primary systemic AL (kappa light chain) amyloidosis

First described by Rokitansky in 1842, and further characterized by Virchow in 1854, amyloidosis is a disorder caused by amyloid deposition, a fibrillary insoluble protein. The clinical spectrum of amyloidosis is broad, as the amyloid deposition may virtually occur in all tissues. Herein, we report the case of a 66-year-old man with a long-lasting emaciating disease, diagnosed, at autopsy, with primary systemic amyloidosis. Amyloid protein deposition was found in many tissues and organs. The involvement of the vessels’ wall rendered ischemic injury most prominent in the intestinal loops causing mesenteric ischemia. Despite the thorough organic involvement, the immediate cause of death was aspiration bronchopneumonia. Massive amyloid deposition was found in virtually all major organs, such as the heart, liver, kidneys, spleen, pancreas, adrenals, prostate, skin, and thyroid: the latter, a complication of the amyloidosis known as amyloid goiter. Post-mortem review of the deceased’s laboratory workup showed a slightly abnormal kappa:lambda ratio in the blood; however, no clonal lymphoplasmacytic disorder was confirmed in the bone marrow and other lymphoreticular system organs either by the microscopic examination and immunohistochemical staining. Laser-capture microdissection and tandem mass spectrometry of the splenic tissue detected a peptide profile consistent with an immunoglobulin Kappa light chain. The presence of amyloid purpura favors the diagnosis of primary systemic amyloidosis.

Secondary Amyloidosis Presenting as Ischemic Proctitis

A 49-year-old man presented with abdominal pain and rectal bleeding for two days associated with a 50-pound unintentional weight loss. History was notable for hypertension, chronic kidney disease, obesity, gout, and acute cholecystitis status post cholecystectomy. Computed tomography (CT) of the abdomen and pelvis showed rectal wall thickening. Colonoscopy showed proctitis with superficial ulcerations. In the setting of renal insufficiency, malabsorption, and low-voltage QRS complexes on electrocardiogram (ECG), amyloidosis was considered in the differential diagnosis. Rectal and renal biopsies with subsequent retrospective staining of gallbladder tissue confirmed amyloid deposition. Gastrointestinal involvement of amyloidosis is relatively uncommon. Particularly, amyloid deposition in the gallbladder and rectum is very rare. The development of AA amyloidosis in our patient may have been related to gout, obesity, and the presence of a heterozygous complex variant for the MEFV (familial Mediterranean fever) gene. Awareness of this atypical presentation of amyloidosis is important, as additional staining of biopsy samples is necessary, and diagnosis allows for directed treatment.

Systemic manifestations - do not forget the small bowel

PURPOSE OF REVIEW

Systemic diseases can afflict the small bowel (SB) but be challenging to diagnose. In this review, we aim to provide a broad overview of these conditions and to summarise their management.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) is an important modality to investigate pathology in the SB. SB imaging can be complementary to SBCE for mural and extramural involvement and detection of multiorgan involvement or lymphadenopathy. Device assisted enteroscopy provides a therapeutic arm, to SBCE enabling histology and therapeutics to be carried out.

SUMMARY

SB endoscopy is essential in the diagnosis, management and monitoring of these multi-system conditions. Collaboration across SB centres to combine experience will help to improve the management of some of these rarer SB conditions.

Primary localized gastric amyloidosis: A scoping review of the literature from clinical presentations to prognosis

Localized gastric amyloidosis (LGA) is a rare disease characterized by abnormal extracellular deposition of amyloid protein restricted to the stomach and it is confirmed by positive results of Congo red staining. Over decades, only a few cases have been reported and studies or research focusing on it are few. Although LGA has a low incidence, patients may suffer a lot from it and require proper diagnosis and management. However, the pathology of LGA remains unknown and no overall review of LGA from its presentations to its prognosis has been published. Patients with LGA are often asymptomatic or manifest atypical symptoms, making it difficult to differentiate from other gastrointestinal diseases. Here, we report the case of a 70-year-old woman with LGA and provide an overview of case reports of LGA available to us. Based on that, we conclude current concepts of clinical manifestations, diagnosis, treatment, and prognosis of LGA, aiming at providing a detailed diagnostic procedure for clinicians and promoting the guidelines of LGA. In addition, a few advanced technologies applied in amyloidosis are also discussed in this review, aiming at providing clinicians with a reference of diagnostic process. With this review, we hope to raise awareness of LGA among the public and clinicians.

Gastrointestinal amyloidosis: A focused review

Amyloidosis, a heterogenous group of disorders, is characterized by the extracellular deposition of autologous, insoluble, fibrillar misfolded proteins. These extracellular proteins deposit in tissues aggregated in ß-pleated sheets arranged in an antiparallel fashion and cause distortion to the tissue architecture and function. In the current literature, about 60 heterogeneous amyloidogenic proteins have been identified, out of which 27 have been associated with human disease. Classified as a rare disease, amyloidosis is known to have a wide range of possible etiologies and clinical manifestations. The exact incidence and prevalence of the disease is currently unknown. In both systemic and localized amyloidosis, there is infiltration of the abnormal proteins in the layers of the gastrointestinal (GI) tract or the liver parenchyma. The gold standard test for establishing a diagnosis is tissue biopsy followed by Congo Red staining and apple-green birefringence of the Congo Red-stained deposits under polarized light. However, not all patients may have a positive tissue confirmation of the disease. In these cases additional workup and referral to a gastroenterologist may be warranted. Along with symptomatic management, the treatment for GI amyloidosis consists of observation or localized surgical excision in patients with localized disease, and treatment of the underlying pathology in cases of systemic amyloidosis. In this review of the literature, we describe the subtypes of amyloidosis, with a primary focus on the epidemiology, pathogenesis, clinical features, diagnosis and treatment strategies available for GI amyloidosis.

Liver and Gastrointestinal Involvement: Update

The organs affected most commonly by AL amyloidosis are the kidneys and heart, however, liver and gastrointestinal (GI) tract are also commonly affected. Symptoms of GI amyloidosis often mimic those of other GI disorders; having a keen awareness of the need to evaluate for amyloidosis is critical in avoiding delay in diagnosis and intervention. GI and liver involvement is associated with significant complications, and challenges in symptomatic management. As with all AL-related organ disease, early systemic treatment can prevent progression of tissue damage and improve outcomes.

Liver and Gastrointestinal Involvement

Early diagnosis of AL amyloidosis and appreciation of the nutritional and coagulation abnormalities associated with liver and gastrointestinal involvement are critically important in the treatment and management. In cases of severe malabsorption total parenteral nutrition can be extremely helpful as a bridge to organ improvement. Rarely the use of antifibrinolytic agents such as oral aminocaproic acid with transfusion support may control severe bleeding in patients with coagulation abnormalities. It is important to keep in mind that organ improvement should follow in lag phase after the reduction in the pathologic free light chain with treatment. Closely following light chain levels may permit brief holidays from treatment and enable periods of recovery before resuming therapy in patients with prompt early and deep hematologic responses.

Localized primary gastric amyloidosis: Three case reports

BACKGROUND

Localized primary gastric amyloidosis is a rare disorder characterized by the extracellular deposition of insoluble fibrillary protein in the stomach and can mimic various diseases on endoscopic examination, including gastrointestinal stromal tumors, gastric cancer and ulcers.

CASE SUMMARIES

Here, we report a series of three cases of localized gastric amyloidosis mimicking gastric mucosa-associated lymphoid tissue (MALT) lymphoma on endoscopic examination that were evaluated over the past ten years in our hospital. The different detection times of this rare disease resulted in three completely different outcomes, indicating the strong importance of early detection, diagnosis and treatment. The difficulties encountered in making an accurate diagnosis and differential diagnosis are highlighted, and this report provides clinical experience for the diagnosis of localized primary gastric amyloidosis.

CONCLUSION

Localized gastric amyloidosis is a rare metabolic disease that resembles MALT lymphoma. Early detection, diagnosis and treatment of localized gastric amyloidosis result in an excellent prognosis.

Comparing Clinical, Imaging, and Physiological Correlates of Intestinal Pseudo-Obstruction: Systemic Sclerosis vs Amyloidosis and Paraneoplastic Syndrome

INTRODUCTION

Intestinal pseudo-obstruction is characterized by impaired transit and luminal dilation in the absence of mechanical obstruction. Our study aims to describe the clinical, radiographic, and physiological findings in pseudo-obstruction associated with systemic sclerosis (SSc), amyloidosis, and paraneoplastic syndrome.

METHODS

A retrospective cohort of patients evaluated at our institution between January 1, 2008, and August 1, 2018, was assembled. Clinical, imaging, and physiological characteristics were abstracted from electronic medical records.

RESULTS

We identified 100 cases of pseudo-obstruction (55 SSc, 27 amyloidosis, and 18 paraneoplastic). Female population predominance was seen in SSc (71%) vs male population in amyloidosis (74%). Most common symptom was abdominal bloating in all 3 groups. Vomiting was more common in SSc than amyloidosis (73% vs 46%, P = 0.02). Diarrhea was more common in amyloidosis and SSc compared with paraneoplastic (81% and 67% vs 28%, P < 0.01). Weight loss (>5%) was more common in SSc compared with amyloidosis and paraneoplastic (78% vs 31% and 17%, P < 0.0001). Only small bowel dilation was seen in 79%, 40%, and 44% and only large bowel dilation in 2%, 44%, and 44% of patients in SSc, amyloidosis, and paraneoplastic, respectively. Five of 8 SSc patients had myopathic and 3 of 5 paraneoplastic had neuropathic involvement on gastroduodenal manometry.

DISCUSSION

SSc-associated pseudo-obstruction demonstrates female population predominance and presents with vomiting, diarrhea, and weight loss. Amyloidosis-associated pseudo-obstruction shows male population predominance. Small bowel is more commonly involved than large bowel on both imaging and transit studies in SSc. Myopathic involvement was more common in SSc, contrary to neuropathic in paraneoplastic syndrome.

Gastric AA amyloidosis secondary to chronic infection presenting with hematemesis: a case report

AA amyloidosis, previously known as secondary amyloidosis, has been associated with multiple chronic inflammatory conditions, including various autoimmune diseases and rarely chronic infection. Hereby, we present a case of AA amyloidosis secondary to chronic infection which initially presented with nausea and hematemesis. Endoscopic biopsies revealed diffuse AA amyloid deposition in the stomach, but not the esophagus. AA Amyloidosis presumably compromised gastric motility, promoted reflux related esophageal ulcers and erosions, and caused his cardiac and renal insufficiency. Therefore, endoscopic biopsies could be practical investigation to identify AA amyloidosis in the setting of chronic inflammatory diseases, especially with multi-organ involvement.

A case report of gastric amyloidosis due to multiple myeloma mimicking gastric cancer

Background

Gastrointestinal (GI) amyloidosis is a rare complication of multiple myeloma (MM). Due to its nonspecific clinical presentation and endoscopic appearance, an early and accurate diagnosis of GI amyloidosis is difficult. Here, we report a case of GI amyloidosis due to MM, which initially presented as GI manifestations mimicking gastric cancer.

Case presentation

A 68-year-old woman presented to the hospital with a 6-month history of anemia, coupled with a recent onset of poor appetite and vomiting for 10 days. Esophagogastroduodenoscopy revealed a gastric antrum mucosal bulge that appeared on visual inspection to be a tumor. As a result, gastric cancer was suspected. However, gastric antrum biopsies demonstrated mild chronic superficial gastritis and esophageal biopsies demonstrated moderate-to-severe atypical hyperplasia of the squamous epithelium. A second endoscopy revealed massive gastric retention and a gastric antrum mucosal bulge with surface erosion. Ultimately, an upper GI tract biopsy demonstrating positive Congo red staining and a bone marrow biopsy indicating plasmacytosis confirmed the diagnosis of gastric amyloidosis due to MM.

Conclusion

This case demonstrates that MM should be considered in patients with nonspecific GI manifestations, and in such cases, a biopsy with Congo red staining should be considered to confirm GI amyloidosis. Early detection of GI amyloidosis will ultimately improve outcomes for these rare patients.

A case of protein-losing gastroenteropathy caused by systemic AA amyloidosis secondary to undifferentiated carcinoma of unknown primary origin

We report the case of a 61-year-old woman with Kartagener syndrome who presented with a 3-month history of chronic watery diarrhoea and severe hypoalbuminaemia. Histopathological examination of duodenum and large intestine biopsies showed amyloid A (AA) amyloid deposition. Scintigraphy and alpha-1 anti-trypsin clearance evaluations revealed protein-losing gastroenteropathy. Computed tomography with contrast and positron emission tomography showed a pelvic mass with multiple para-aortic lymph node enlargement. We suspected protein-losing gastroenteropathy secondary to AA amyloid produced related to malignant tumours. Following tumour resection, histopathological examination of the lesion revealed undifferentiated carcinoma of unknown origin. Postoperatively, the patient’s nutritional condition improved. There has been no recurrence of protein-losing gastroenteropathy 6 months postoperatively. This is the first report of protein-losing gastroenteropathy and AA amyloidosis secondary to undifferentiated carcinoma. Early recognition and intervention could increase the likelihood of amyloidosis remission.

Clinical and endoscopic manifestations of gastrointestinal amyloidosis: a case series

Gastrointestinal (GI) amyloidosis is rare and has varying clinical and endoscopic presentations. In this case series, we present three patients with primary systemic amyloid-light chain (AL) amyloidosis with GI involvement and complications of GI bleeding. We also provide a brief review of the literature, including clinical presentation, endoscopic findings, pathology, and management of GI amyloidosis. The endoscopic findings of GI amyloidosis can vary, including friable mucosa with erosions, ulcers, and submucosal hematomas or mucosal thickening with polypoid protrusions. The endoscopic findings may correlate with the pathologic deposition of amyloid fibrils. Treatment of GI amyloidosis is generally focused on management of the underlying condition and supportive care. Gastroenterologists should be familiar with the endoscopic findings as they may be the first suggestion of disease and allow for definitive diagnosis.

Chronic intestinal pseudo-obstruction due to al amyloidosis: a case report and literature review

A 59-year-old woman presented to our hospital with a 6-month history of nausea, weight loss, and abdominal distension. Physical examination revealed abdominal distension without tenderness, and edema, numbness, and multiple peripheral neuropathy in the limbs. Blood test results showed anemia, hypoproteinemia, and hypoalbuminemia. Immunoelectrophoresis detected kappa-type Bence-Jones protein in both the serum and urine. Bone marrow examination did not reveal an increase of plasma cells. Computed tomography showed intestinal distension and retention of intestinal contents. No obstructive intestinal lesions were observed. Lower gastrointestinal endoscopy showed a decrease in the vascular visibility of the rectal mucosa. Histological findings showed amyloid deposition, which was positive for amyloid light-chain (AL) κ. Thus, she was diagnosed with chronic intestinal pseudo-obstruction (CIPO) due to gastrointestinal and neurological involvement of AL amyloidosis. Her abdominal symptoms were gradually improved by the insertion of an ileus tube and medication. Although we recommended chemotherapy for stopping her disease progression, she did not want to receive it. She died 1 year later because of her pneumonia. We should keep in mind that amyloidosis is an important cause of CIPO. Histopathological examination by endoscopic biopsy is required for exact diagnosis and appropriate treatment for CIPO due to amyloidosis.

Small Bowel Amyloidosis

PURPOSE OF REVIEW

The goal of this paper is to review the literature on small bowel amyloidosis. Our review focuses on the underlying etiology, histopathology, clinical features, endoscopic and radiologic findings, and the mainstay of management.

RECENT FINDINGS

The latest research shows changing epidemiological trends of different types of amyloidosis. It also reveals a better understanding of its pathophysiology and shows improvement in treatment outcomes. Amyloidosis is a group of diseases of multiple etiologies and clinical presentations. It is characterized by pathological deposition of insoluble fibrillar proteins within various organs leading to disruption of their structure and function. The classification of amyloidosis includes primary, secondary, dialysis-related, senile, and hereditary. Amyloidosis can be systemic or localized. The incidence of AA amyloidosis is declining in frequency. If the gastrointestinal (GI) tract is involved, the small intestine is the most commonly affected site. Overall, outcomes among patients with newly diagnosed amyloidosis have improved. This article focuses on small bowel amyloidosis.

Systemic amyloidosis with gastrointestinal involvement: Diagnosis from endoscopic and histological views

Amyloid tends to deposit in the gastrointestinal tract, which, being easily accessible, is often the target organ for a pathological diagnostic examination. Although a mucosal biopsy is necessary for a definitive diagnosis and several studies have reported positive results for each possible biopsy site, there remain many unclear features in various aspects. This review focuses on the current literature to determine a better understanding of the diagnosis from endoscopic and histological views in patients with systemic amyloidosis with gastrointestinal involvement. A literature search was performed using PubMed to identify relevant studies; linked references were also reviewed. Endoscopic findings vary based on the organ and the depositing amyloids. A fine granular appearance or polypoid protrusions are likely to occur in the duodenum. AL, Aβ2M, and ATTR amyloids are likely to deposit submucosally, while AA amyloid is easily deposited in the superficial layer of the mucous membrane. Furthermore, it is necessary to consider the collection of biopsy specimens from the duodenum, which has high positive biopsy rates. However, the difference in the positive biopsy rates depends on whether endoscopic findings are available or whether the appropriate number has not been fully elucidated. A duodenal biopsy is strongly recommended to confirm the deposition of amyloid in patients with systemic amyloidosis having gastrointestinal involvement. Because amyloidosis is a disease with a poor prognosis, early diagnosis and treatment are required; gastroenterologists and endoscopists play important roles.

Diffuse Peritoneal and Bowel Wall Infiltration by Light Chain-AL Amyloidosis with Omental Calcification Mimicking Abdominal Carcinomatosis - An Elderly Female with Incidental Finding of Light Chain Monoclonal Gammopathy of Undetermined Significance (LC-MGUS)

Patient: Female, 68

Final Diagnosis: Light chain monoclonal gammopathy of undetermined significance

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Oncology

Incomplete ileus and hemafecia as the presenting features of multi-organ involved primary systemic AL amyloidosis: a rare case report

Background

AL Amyloidosis is known to be a systemic disease affecting multiple organs and tissue while it’s rare that patients present with gastrointestinal symptoms at first and later develop multiple-organ dysfuction. Clinical signs are not specific and the diagnosis is rarely given before performing immunofixation and endoscopy with multiple biopsies. We would like to emphasize the value of precise diagnostic process of AL amyloidosis.

Case presentation

In this case report, we describe a 56-year-old man who presented with recurrent periumbilical pain for 4 months and gradually worsened over a month. After a series of tests, he was finally diagnosed with primary systemic AL amyloidosis. He was treated with a chemotherapy regimen (Melphalan, dexamethasone and thalidomide) achieving a good clinical response.

Conclusion

On account of the high misdiagnosis rate, establishing the most precise diagnosis in first time with typing amyloidogenic protein becomes increasingly vital. Although the presenting feature is usually nonspecific, AL amyloidosis ought to be considered when multiple organs are involved in a short period.

Gastrointestinal Tract Amyloidosis Presenting With Pneumatosis Intestinalis

Pneumatosis intestinalis is a radiographic finding of gas pockets within the bowel wall. It can be associated with a range of diagnoses, but the most life-threatening causes are mesenteric ischemia, bowel necrosis, and bowel obstruction. Here we present the case of a patient with multiple myeloma who had pneumatosis intestinalis due to gastrointestinal amyloidosis, which is a rare manifestation of systemic amyloid disease. The patient had both transthyretin (ATTR) amyloidosis and acquired apolipoprotein serum amyloid A (AA) amyloidosis that are not usually seen in conjunction with multiple myeloma, which is most commonly associated with light-chain (AL) amyloidosis. This case highlights the importance of considering Congo red staining of bowel biopsies for amyloid deposition in patients undergoing endoscopy for unexplained gastrointestinal tract symptoms and even pneumatosis intestinalis, so as to avoid a delay in diagnosis that is typically seen with amyloidosis. Since each subtype of amyloidosis requires different therapy, amyloid subtyping is crucial, even with co-existing multiple myeloma.