An Atypical Place for Amyloidosis

Abstract

Amyloidosis is the abnormal extracellular tissue deposition of insoluble, pathologic fibrils composed of antiparallel beta-pleated sheets. Deposition can be systemic or organ-specific. Symptomatic gastric amyloidosis is rare given that only 0.08% of those afflicted with the disease demonstrate gastrointestinal bleeding, malabsorption, protein-losing gastroenteropathy, and chronic gastrointestinal dysmotility. A known correlation exists between multiple myeloma and amyloidosis. This is a case of a 75 year old male with multiple myeloma who was found to have gastric and duodenal amyloidosis on evaluation of nausea, abdominal pain and dysphagia with EGD. For his multiple myeloma the patient underwent treatment for several months with dexamethasone, cyclophosphamide, and bortezomide. On a follow up visit, he endorsed several weeks of nausea, epigastric abdominal pain and dysphagia (mainly to solids) and thus EGD was performed. He was found to have a mild, non-obstructing Schatzki ring at the gastroesophageal junction. It was dilated to a maximum TTS balloon size of 20mm with complete resolution of luminal narrowing. He was also found to have localized moderately erythematous mucosa without bleeding in the gastric antrum as well as two 5mm non-bleeding cratered duodenal bulb ulcers with no stigmata of bleeding. These sites were biopsied and confirmed to have abundant amyloid deposition in the lamina propria via the Congo red special stain. Amyloid deposition can occur in the lower esophageal sphincter thereby decreasing lower esophageal sphincter pressure and cause symptoms of dysphagia and acid reflux, however typical symptoms of gastrointestinal amyloidosis include hematochezia, melena, malabsorption and dysmotility. Gastric amyloidosis, though rare, should be considered on differential diagnosis in individuals with known multiple myeloma who present with nausea, abdominal pain and dysphagia.