Khan Zubair, Darr Umar, Renno Anas, Tiwari Abhinav, Sofi Aijaz, Nawras Ali
Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio, USA.
Division of Gastroenterology, University of Toledo, Toledo, Ohio, USA.
Case Rep Gastroenterol. 2017 Oct 30;11(3):625-631. doi: 10.1159/000480073. eCollection 2017 Sep-Dec.
Symptomatic primary (amyloid light-chain or AL) amyloidosis of the gastrointestinal (GI) tract is very rare. Most of the patients with symptomatic involvement of the GI tract present with altered motility, malabsorption, or bleeding. We report a case of gastric and colonic amyloidosis on anticoagulation presenting with massive upper and lower GI bleeding. A 67-year-old lady known to have multiple myeloma and AL amyloidosis on rivaroxaban presented with massive upper GI bleeding. Esophagogastroduodenoscopy showed a mass lesion (3 × 7 cm) located along the greater curvature in the body/antrum with active bleeding. Mucosal biopsies revealed amyloid deposition. She underwent partial gastrectomy and recovered well after surgery, and was discharged home on rivaroxaban. The patient presented again 4 weeks after discharge with bleeding per rectum, and a colonoscopy revealed a large mass in the proximal transverse colon with active bleeding. Biopsy of the mass showed amyloid deposition. At this point, the patient declined any further intervention. Rivaroxaban was discontinued, the rectal bleeding stopped, and she was discharged home with no further episodes of GI bleed. Amyloidosis of the GI tract presenting with massive GI bleed is extremely rare and is thought to be related to small-vessel fragility due to amyloid infiltration and impaired hemostasis caused by factor X deficiency. Even though GI bleeding with amyloidosis is spontaneous, use of anticoagulation could activate such episodes in these patients. Caution should be exercised with the use of anticoagulation in patients with amyloidosis involving the GI tract, and colonoscopy should be considered in patients with gastric amyloidosis.
有症状的原发性（淀粉样轻链或AL）胃肠道淀粉样变性非常罕见。大多数有胃肠道症状的患者表现为动力改变、吸收不良或出血。我们报告一例抗凝治疗期间发生胃和结肠淀粉样变性并出现大量上、下消化道出血的病例。一名67岁女性，已知患有多发性骨髓瘤和AL淀粉样变性，正在服用利伐沙班，出现大量上消化道出血。食管胃十二指肠镜检查显示在胃体/胃窦大弯处有一个肿块病变（3×7cm），伴有活动性出血。黏膜活检显示有淀粉样沉积。她接受了胃部分切除术，术后恢复良好，出院时继续服用利伐沙班。患者出院4周后再次出现直肠出血，结肠镜检查显示横结肠近端有一个大肿块，伴有活动性出血。肿块活检显示有淀粉样沉积。此时，患者拒绝进一步干预。停用利伐沙班后，直肠出血停止，她出院回家，未再发生消化道出血。以大量消化道出血为表现的胃肠道淀粉样变性极为罕见，被认为与淀粉样浸润导致的小血管脆性增加以及X因子缺乏引起的止血功能受损有关。尽管淀粉样变性患者的消化道出血是自发的，但抗凝治疗可能会引发这些患者的此类发作。对于累及胃肠道的淀粉样变性患者，使用抗凝剂时应谨慎，对于胃淀粉样变性患者应考虑进行结肠镜检查。
