Symptomatic Primary (AL) Amyloidosis of the Stomach and Duodenum

Primary (AL) amyloidosis of the gastrointestinal tract is relatively rare, and symptomatic amyloidosis of the stomach is even more seldom. We present the case of a patient who was referred to upper endoscopy because of weight loss, nausea, and vomiting. Large areas of intramucosal hemorrhages were seen, and biopsies resulted in profuse bleeding stopped with endoscopic clips. The biopsies showed amyloid depositions and further workup revealed that the patient also had cardiac and neuropathic involvements. The patient started treatment with dexamethasone, melphalan and bortezomib. After treatment was started the nausea and epigastric discomfort improved, and a reduction in the biochemical markers troponin T, NT-proBNP, and M-component was observed. Gastric amyloidosis is rarely seen at upper endoscopy in patients without a previously established diagnosis, but the unusual endoscopic findings and bleeding tendency after biopsy should be kept in mind by gastroenterologists. 1. Introduction Gastrointestinal involvement in amyloidosis is seen in primary (AL) amyloidosis, secondary (AA) amyloidosis, and dialysis-related (β2-microglobulin) amyloidosis. Primary (AL) amyloidosis of the gastrointestinal tract is relatively rare, and only 8% of patients were reported to have amyloidosis in biopsies from the GI tract, whereas only 1% had symptomatic amyloidosis of the stomach in a series of 769 patients [1]. Amyloidosis involving the gastrointestinal tract may cause symptoms related to altered motility, gastrointestinal bleeding, or malabsorption. In the stomach, gastric amyloidosis may have an endoscopic appearance mimicking gastric neoplasia [2, 3], hematomas, erosions and ulcerations, or a nodular gastritis [4]. The diagnosis of gastrointestinal amyloidosis may be hard to suspect in patients without previously diagnosed inflammatory or plasma cell disease. 2. Case A 74-year-old woman was referred to upper gastrointestinal endoscopy due to weight loss of 10？kg in 6 months, epigastric discomfort, nausea, and episodes of vomiting. She had a previous history of a tachy-brady syndrome resulting in pacemaker implantation two years before and received metoprolol treatment. Upper endoscopy showed large areas of intramucosal hemorrhage, mainly in the corpus and cardia of the stomach, whereas in the duodenal bulb, there was a polypoid lesion (Figure 1). A biopsy was taken from a small area with modest signs of intramucosal hemorrhage resulted in a profuse bleeding that was stopped with endoscopic clips. Biopsy collection from the polypoid lesion in the duodenum was