S2133 Amyloidosis-Associated Gastric Ulceration and Submucosal Hematoma

Abstract

INTRODUCTION: A 77-year-old woman with a history of atrial fibrillation treated with apixaban presented to the hospital after a presyncopal event and hematemesis. Endoscopic evaluation revealed a large submucosal hematoma, which was initially suspicious for an isolated gastric varix, and 2 large gastric ulcers which biopsy later identified as amyloidosis. CASE DESCRIPTION/METHODS: A 77-year-old woman with a history of atrial fibrillation treated with apixaban presented to the hospital after a presyncopal event. Approximately 12 hours after admission, she was noted to have frank hematemesis, requiring IV fluids, blood, and plasma transfusion. EGD demonstrated copious clotted blood in the gastric fundus and a submucosal lesion which appeared to be an isolated varix in the gastric body. The patient was then transferred to a tertiary care center to be evaluated for endoscopic cyanoacrylate therapy. Upon arrival, she was noted to have intermittent episodes of bradycardia, but otherwise remained stable. She experienced no additional episodes of GI bleeding. Repeat EGD demonstrated 2 large, clean-based gastric ulcers with beefy-red margins. Biopsy later identified these as amyloidosis. No interventions were performed on the gastric lesion initially thought to be a gastric varix. This lesion was likely a submucosal hematoma. The patient was discharged to home in stable condition on twice-daily proton-pump inhibitor therapy. DISCUSSION: Amyloidosis is characterized by the pathologic deposition of proteins throughout the body. Within the GI tract, this deposition increases the frailty of blood vessels, hinders intrinsic peristalsis and decreases the compliance of the gut wall, and may present with varying degrees of upper and lower GI bleeding. Cardiac conduction abnormalities are also associated with amyloidosis. The cornerstone of treatment for acquired amyloidosis is the treatment of the underlying disorder causing elevated amyloid precursors. Uniquely, amyloidosis is also associated with submucosal hematoma. The patient in this case presented with massive upper GI bleeding due to amyloid-induced ulcers, and bleeding from these ulcers was exacerbated by apixaban use. Two unique findings suggesting amyloidosis were unexplained bradycardia and a prominent gastric submucosal hematoma (initially thought to be a gastric varix), both of which are highly associated with amyloidosis. Although the patient was discharged in stable condition, she remains at high risk of morbidity and mortality from this systemic disease.Figure 1.: Large gastric body ulcer with prominent beefy-red margins. Biopsies from ulcer margins showed amyloidosis.Figure 2.: Two large amyloidosis-associated gastric ulcers on opposing walls of the gastric body.Figure 3.: This amyloidosis-associated submucosal hematoma was initially mistaken for a gastric varix.