1975 Not Your Typical GI Bleeding: Gastrointestinal Involvement in Systemic Amyloidosis

Abstract

INTRODUCTION: Systemic amyloidosis is a rare disease that occurs preeminently in the elderly and can affect different kind of organ systems depending on the locality of amyloid build-up. Most typically fibril formation causes damage to the kidney and heart. Here, we report the case of a man with systemic amyloidosis and sudden onset of Hematochezia. CASE DESCRIPTION/METHODS: A 90 y/o male with a history of chronic heart failure due to amyloidosis of unknown origin, CAD, AFib, HTN, HLD, OSAS, peripheral vascular disease, CKD and diverticulosis presented to the ED with one episode of bright red blood per rectum and microcytic anemia. On arrival patient did not have any abdominal pain, nausea, vomiting, or diarrhea. He continued to have several bloody episodes. Rectal exam showed bright red blood with clot and hard brown Bristol 1 stool balls without blood. Initial work up including CBC, CMP, and coags was notable for Hb 9.7 g/dl, Plts 137 × 10(3)/uL, Troponin 0.19 ng/mL, PT 36.6s, and INR 2.8. The patient received IV fluids and 3 units of RBCs, blood thinners and anti-platelet medication were held, and patient was prepped for colonoscopy. Endoscopy showed diffuse, friable, patchy, hemorrhagic mucosa in the transverse colon, hepatic flexure, ascending colon, and cecum, consistent with amyloid. Diverticulosis was confirmed with no evidence of active bleeding. No endoscopic interventions were performed given minimal benefit and risk of high rebleeding. DISCUSSION: There are about 30 different types of amyloidosis with a varying spectrum of clinical presentation.[i] In a retrospective study 3% of patients with amyloidosis had biopsy proven involvement in the GI tract.[ii] Intestinal involvement usually presents clinically with either GI bleeding, malabsorption, protein-losing gastro-enteropathy, or chronic gastrointestinal dysmotility. Given his cardiac and abdominal history and presentation with lower GI bleeding differential diagnosis were initially drawn to diverticular bleeding versus ischemic colitis. In this case, the colonoscopy results and pre-condition of amyloidosis were attributed to be the cause of hematochezia. Biopsies were not collected given bleeding risk and low impact on further management.