Multiple Myeloma Presenting as Acute GI Bleed and Adynamic Colon

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Introduction: Multiple myeloma (MM) is a monoclonal plasma cell neoplasm of the bone marrow that produces specific immunoglobulin (Ig). Extramedullary organ involvement is very rare; characterized by infiltrative disease inform of amyloidosis or plasmacytoma. Gastrointestinal amyloidosis (GIA) results from either mucosal or neuromuscular infiltration. Systemic amyloid deposition are mostly AL or AA amyloid caused by a plasma cell dyscrasia or recurring inflammation, respectively. Herein, we present a case of patient who initially presented with GI bleed constipation due to GIA - AL. Case: 64 y/o female with a history of atrial fibrillation, h/o bleeding gastric ulcer on pantoprazole presented to ED for elective ablation. Her physical exam and VS were within normal limits. Hospital course was complicated by melena. Patient had an upper and lower endoscopy which found an ulcerated antral mass with heaped up edges (Forest Class III) and external hemorrhoids, respectively. Biopsy of the antral mass did not identify malignancy. After failure to resolve on empiric PPI therapy, the repeat biopsy was stained for amyloid. (image 1). Bone marrow biopsy revealed, multiple myeloma with Immunofixation significant for IgG kappa monoclonal protein. Patient was started on chemotherapy. Patient was readmitted after two months with nausea, vomiting, and obstipation after failing outpatient regimen of poly-ethylene glycol (PEG)and fleet enemas for 5 days. Physical exam was significant for distended abdomen with hypoactive bowel sounds. CT scan abdomen and pelvis revealed fecal material throughout colon with a possible transition point at sigmoid colon. Patient improved after manual disimpaction. Colonoscopy did not find any evidence of colonic obstruction, but patchy ulcerated mucosa was biopsied. The biopsies revealed presence of thickened muscularis mucosa due to amyloid deposition (Image 2). Patient was discharged home on linaclotide and daily PEG with relief. Discussion: This case highlights an atypical presentation of multiple myeloma in form of amyloidosis, gastric hemorrhage with progressive colonic atony despite initiation of chemotherapy. Symptomatic GIA can present as bleeding, malabsorption, or protein-losing enteropathy; however gastrointestinal dysmotility is a very uncommon presentation. The presence of GIA should prompt a search for possible etiologies such as MM. Staining for amyloid should be considered in a patient with unresolved GI inflammation.Figure: Gastric antrum(endoscopy with Histology).Figure: Descending colon(Colonoscopy and histology).