A Rare Cause of Gastric Outlet Obstruction

Abstract

Introduction: Amyloidosis can affect the gastrointestinal tract however it is rare for patients to present with gastric outlet obstruction (GOO). Case Description: A 69 years old female with significant past medical history of ischemic colitis, non-ischemic cardiomyopathy and diabetes presented with a 1 month history of early satiety and abdominal distension in addition to four days of acute nausea and vomiting with inability to tolerate PO intake. Of note, the patient had also developed macroglossia and angioedema over the last several months, and was being evaluated by allergy and immunology. Work up including blood work and skin testing was unrevealing. On presentation, she had a CT abdomen pelvis which showed a massively dilated stomach with a transition point in the proximal duodenum consistent with GOO. A nasogastric tube was placed for decompression and G.I was consulted. She underwent intubation for airway protection and EGD was performed. EGD showed massive fluid filled stomach with retained food particles. To decompress the stomach the endoscope was removed, and a 34 F Ewald gastric tube from an adult gastric lavage kit was advanced into the stomach. Approximately 4 liters of fluid and innumerable large food particles were removed with copious irrigation. The endoscope was then reinserted and passed to the duodenal bulb. There was no intraluminal mass. The antral walls appeared thickened with diffuse stasis gastritis. Multiple gastric biopsies were taken. Biopsies were positive for congo red stain and characteristics consistent with AL amyloidosis. Patient underwent further cardiac work up and a bone marrow biopsy consistent with cardiac amyloidosis and multiple myeloma for which chemotherapy was initiated.Figure: CT scan.Discussion: Gastrointestinal amyloidosis can have a wide array of clinical manifestations, including reflux, dysphagia, obstruction, infarction, perforation, bleeding, malabsorption, or chronic gastrointestinal dysmotility/pseudo-obstruction. It is however, a rare cause of gastric outlet obstruction. For patients that do present with chronic dysmotility, impaction of the antrum with food particles may cause an acute presentation. Gastric amyloidosis should be considered as a cause of GOO when other common causes such as mechanical obstruction from peptic ulcer disease or gastric cancer have been ruled out. Large bore gastric lavage systems can allow for decompression of the stomach and better endoscopic visualization in these challenging cases.Figure: Upper endoscopy.Figure: Pathology.