An Unsusual Case of Lower Gastrointestinal Bleeding

Patient: Female, 81 Final Diagnosis: Gastrointestinal amyloidosis Symptoms: Gastrointesinal haemorrhage • hypotension Medication: — Clinical Procedure: Endoscopy Specialty: Criitcal Care Medicine OBJECTIVE: Challenging differential diagnosis BACKGROUND: Amyloidosis is a multisystem disease, and can present with multitude of nonspecific symptoms. Gastrointestinal amyloidosis is common, and gastrointestinal (GI) bleeding in these patients has a wide differential diagnosis. The present case features the distinctive endoscopic finding of submucosal hematoma as a clue to immunoglobin light chain (AL) amyloid involvement of the gastrointestinal tract. CASE REPORT: An 81-year-old woman with AL amyloidosis was transferred to the intensive care unit (ICU) for evaluation of GI bleeding. Prior to the bleeding episode, the patient had undergone paracentesis for management of her ascites related to restrictive cardiomyopathy. Initial evaluation was negative for any intra-abdominal catastrophe related to her recent paracentesis. Upper gastrointestinal endoscopy was negative for any source of bleeding. However, colonoscopy showed a ruptured submucosal hematoma, which is a rare but classical finding in patients with amyloidosis. The patient was managed conservatively and did not have any further episodes of bleeding in the hospital. She unfortunately died due to her primary illness 6 weeks after discharge from the hospital. CONCLUSIONS: The finding of submucosal hematoma on endoscopy is a rare but sentinel sign for amyloidosis involvement in the GI tract.