Gastic Mucosal Calcinosis Associated With Gastrointestinal Bleeding

Abstract

Purpose: Gastric mucosal calcinosis (GMC) is a rare cause of gastrointestinal bleeding, and usually an incidental finding on endoscopy. Histopathology characteristically reveals deposits of irregular, amorphous microcalcifications in the gastric mucosa. GMC is classified as metastatic, dystrophic or idiopathic. Metastatic calcinosis is the most common, occurring in the setting of abnormal calciumphosphate metabolism, and resulting in deposition of calcium salts. We report a case of gastric mucosal calcinosis associated with overt gastrointestinal bleed. Case: A 59 year old Hispanic man presented with 1 week of black stools. Past medical history included end stage renal disease on hemodialysis for 8 years, atrial fibrillation on anticoagulation, diabetes, and coronary artery disease. He denied nausea, vomiting, hematemesis, or abdominal pain. No NSAID use other than daily aspirin was reported. Vital signs on presentation were unremarkable. Physical exam was notable for pale conjunctiva, soft, non-tender abdomen, and melena on rectal exam. Laboratory tests revealed hemoglobin of 5.9 g/dL (baseline 10 g/dL), creatinine 5.87 mg/dL, corrected calcium 9.3 mg/dL, phosphorus 3.4 mg/dL, calcium-phosphate product 31, and INR 2.8. The patient received 2 units of packed red blood cells and 4 units of fresh frozen plasma with appropriate response. EGD showed thickened antral folds (Figure 1), which were further evaluated with endoscopic ultrasound showing hyperechoic foci and shadowing with intact gastric layers (Figure 2). Histopathology of thickened folds showed foveolar hyperplasia and histiocytes in the lamina propria containing calcium deposits. Von Kossa stain confirmed calcium deposition (Figure 3). Steiner stain was negative for Helicobacter pylori. No other source of bleeding was identified on repeat EGD, colonoscopy, and capsule endoscopy. At 4 months follow up, patient has had no further bleeding.Figure 1Figure 2Figure 3Conclusions: The presentation above is suggestive of upper GI bleed secondary to gastric mucosal calcinosis in the setting of end stage renal disease. GMC has been rarely reported as a cause of GI bleeding. This case emphasizes that gastric mucosal calcinosis should be considered as a possible GI bleeding source especially in the clinical setting of chronic kidney disease.