Gastrointestinal Bleeding & Gastroparesis Secondary to Amyloidosis

Abstract

Purpose: Amyloidosis is common in multiple myeloma; however, extensive gastrointestinal tract involvement without involvement of other organ systems is extremely rare. We are describing a case of gastroparesis and gastrointestinal bleeding associated with kappa light chain multiple myeloma. A 55 year old female with kappa light chain multiple myeloma and a fourteen month history of chemotherapy, was admitted with complaints of nausea, vomiting, and rectal bleeding of five days duration. Five months prior to admission, patient had a gastrointestinal work-up because of recurrent vomiting and guaiac positive stool, which revealed gastritis and internal hemorrhoids. The patient had type II diabetes mellitus, without diabetic triopathy and hemoglobin A1c was less than 6. Patient did not have a history of renal failure or thyroid disease. Echocardiography was negative for any signs of cardiac amyloidosis. On physical examination, she was lethargic and appeared cachectic. She had bibasilar crackles and diminished breath sounds in right lower lobe. The patient had 2 + pitting edema in the lower extremities. Laboratory data were within normal range except for hemoglobin of 7.8, with a drop from 8.8 one week prior to admission. Gastroparesis was confirmed on gastric scintigraphy (nuclear gastric emptying study). Friable gastric mucosa with active oozing of blood was noted on upper endoscopy. Bleeding was controlled with injection of submucosal epinephrine and gold probe therapy. Due to persistent nausea and vomiting, a second upper endoscopy was done and revealed edematous mucosa of pylorus and several regions of submucosal bleeding. There was no evidence of gastric outlet obstruction. Antral and pyloric biopsies revealed active gastritis with submucosal pink material and special stains for amyloid were positive. Patient was treated with metoclopramide and intravenous erythromycin and was discharged home on regular diet. Conclusion: Amyloid is a fibrous protein with local extracellular deposition that can involve any organ system and present with or without clinical manifestations. Our patient's chronic anemia is multifactorial including components of multiple myeloma and chronic gastrointestinal bleeding secondary to amyloidosis. Gastroparesis is common in familial amyloidotic polyneuropathy but infrequent in patients with kappa light chain multiple myeloma.