Duodenal Amyloidosis in a Patient With Multiple Myeloma: 1853

Amyloidosis is a complication of multiple myeloma that can cause gastrointestinal (GI) bleeding when it deposits in the wall of the GI tract. Here we report a patient with a history of multiple myeloma who presented with melena and was discovered to have duodenal amyloidosis. A 74 year old male with known history of stage III Multiple Myeloma (MM) presented to the emergency department with melena of a few days duration. It was associated with increasing weakness and lightheadedness with minimal exertion. He denied any nausea, vomiting or abdominal pain. Past medical history is also remarkable for recent deep vein thrombosis currently being treated with enoxaparin. On physical exam, BP 98/59, HR 112 with signs of dehydration and otherwise unremarkable. Immediate resuscitative measures were initiated. Laboratory work up showed Hb of 5.9. The patient subsequently received a total of 6 units of packed red blood cells throughout his hospital course. Gastroenterology was consulted and the patient underwent esophagogastroduodenoscopy that showed a large post bulbar ulceration in the distal duodenum with minimal bleeding.(Figure 1-2). Gastrin level was obtained given the location and the size of the ulceration and returned normal and biopsies confirmed the diagnosis of amyloidosis. Post-operatively, the patient's Hb was stable and he remained asymptomatic. An inferior vena cava filter was placed given the contraindication for anticoagulation. Amyloidosis is a complication in patients with multiple myeloma that can affect any organ in the body, including the gastrointestinal (GI) tract. The most commonly affected portion of the GI tract is the duodenum, followed by the stomach and colorectum. However, biopsy-proven amyloidosis is very uncommon. Some cases, like this one, present in the absence of systemic amyloidosis hence why this diagnosis should be considered in those with MM and a GI bleed. Biopsies using congo red stain should be obtained. Furthermore, GI bleed can be the initial manifestation of multiple myeloma. Therefore, in a patient with unexplained refractory GI bleeding, multiple myeloma must remain on the differential. Systemic amyloidosis can be treated with anti-plasma cell therapy and those with localized amyloidosis may be observed effectively with supportive care.Figure: The large ulcerative lesion as seen via endoscopy.Figure: The large ulcerative lesion as seen via endoscopy.