Hemorrhagic bullous colitis as a primary manifestation of AL amyloidosis

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.

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.

A multiple myeloma patient who developed ischemic colitis during lenalidomide treatment: A rare case report

INTRODUCTION

Multiple myeloma is a malignant neoplasm of plasma cells. Lenalidomide-dexamethasone treatment is a common treatment regimen used in refractory multiple myeloma.

CASE REPORT

We describe the case of a 58-year-old male multiple myeloma patient with a history of relapse after six months of autologous stem cell transplantation. The patient had nausea and bloody diarrhea developed during lenalidomide treatment.Management and outcome: Computed tomography showed diffuse marked edematous thickness in the wall of colonic, hepatic and splenic flexure, transverse colon, descending colon and sigmoid colon. Colonoscopic observation revealed highly granular, hyperemic and fragile mucosa. Colon biopsy was consistent with ischemic colitis. Lenalidomide treatment was discontinued. One month later, colon findings were detected as normalized through a colonoscopy.

DISCUSSION

Risk of developing ischemic colitis should be kept in mind in patients receiving lenalidomide which should be discontinued in cases with severe bloody diarrhea of unknown origin.

Endoscopic and histopathological features of gastrointestinal amyloidosis

Amyloidosis is a rare disorder, characterized by the extracellular deposition of an abnormal fibrillar protein, which disrupts tissue structure and function. Amyloidosis can be acquired or hereditary, and systemic or localized to a single organ, such as the gastrointestinal (GI) tract. Clinical manifestations may vary from asymptomatic to fatal forms. Primary amyloidosis (monoclonal immunoglobulin light chains, AL) is the most common form of amyloidosis. AL amyloidosis has been associated with plasma cell dyscrasias, such as, multiple myeloma. Secondary amyloidosis is caused by the deposition of fragments of the circulating acute-phase reactant, serum amyloid A protein (SAA). Common causes of AA amyloidosis are chronic inflammatory disorders. Although GI symptoms are usually nonspecific, histopathological patterns of amyloid deposition are associated with clinical and endoscopic features. Amyloid deposition in the muscularis mucosae, submucosa, and muscularis propria has been dominant in AL amyloidosis, leading to polypoid protrusions and thickening of the valvulae conniventes, whereas granular amyloid deposition mainly in the propria mucosae has been related to AA amyloidosis, resulting in the fine granular appearance, mucosal friability, and erosions. As a result, AL amyloidosis usually presents with constipation, mechanical obstruction, or chronic intestinal pseudo-obstruction while AA amyloidosis presents with diarrhea and malabsorption Amyloidotic GI symptoms are mostly refractory and have a negative impact on quality of life and survival. Diagnosing GI amyloidosis requires high suspicion of evaluating endoscopists. Because of the absence of specific treatments for reducing the abundance of the amyloidogenic precursor protein, we should be aware of certain associations between patterns of amyloid deposition and clinical and endoscopic features.

Amyloid and the GI tract

Amyloidosis is characterized by the extracellular deposition of an abnormal fibrillar protein, which disrupts tissue structure and function. Amyloid may be localized to a single organ, such as the GI tract, or be systemic where the amyloid type is defined by the respective fibril precursor protein. Among patients with systemic amyloidosis, histological involvement of the gastrointestinal (GI) tract is very common but often subclinical. The presence and pattern of GI symptoms varies substantially, not only between the different amyloid types but also within them. GI presentations are frequently nonspecific and include macroglossia, dyspepsia, hemorrhage, a change in bowel habit and malabsorption. Endoscopic and radiological features of amyloidosis are also nonspecific, with the small intestine most commonly affected. In the absence of specific treatments for GI amyloidosis, therapy is aimed at reducing or eliminating the supply of the respective fibril precursor protein. Supportive measures such as nutritional support and antidiarrheal agents should be instigated while awaiting the clinical improvement associated with a successful reduction in the abundance of the fibril precursor protein. GI tract surgery should be performed only if the benefits clearly outweigh the risks, as there is a risk of decompensation of organs affected by amyloid.

Systemic amyloidosis and the gastrointestinal tract

Systemic amyloidosis is characterized by the extracellular deposition of protein in an abnormal fibrillar form. Several different types of amyloidosis exist, each defined by the identity of their respective fibril precursor protein. Among patients with systemic amyloidosis, histological involvement of the gastrointestinal tract is very common but is often subclinical. Conversely, primary diseases of the gastrointestinal tract can cause systemic amyloidosis; for example, AA amyloidosis can occur secondary to IBD. The presence and pattern of gastrointestinal symptoms varies substantially, not only between the different types of amyloidosis but also within them. Typical clinical presentations, most of which are nonspecific, include macroglossia, hemorrhage, motility disorders, disturbance of bowel habit and malabsorption. Endoscopic and radiological features are also nonspecific, with the small intestine most commonly affected. Currently, the aim of therapy for amyloidosis is to slow amyloid formation by reducing the abundance of the fibril precursor protein. No specific treatments for the gastrointestinal symptoms of systemic amyloidosis are available; however, case reports and small published series encourage nutritional support for patients with motility disorders and pharmacological agents for treatment of diarrhea. Surgical procedures should be contemplated only in an emergency setting because of the risk of decompensation of organs affected by amyloid deposition.