Amyloidosis and the gut

Amyloidosis mimics achalasia's effect on lower esophageal sphincter

Esophageal involvement in systemic amyloidosis is common. Manometric studies have been few in number and have revealed a variety of findings compatible with deposition of amyloid in myopathic as well as neuropathic patterns. This report describes a patient with primary amyloid whose esophageal dysfunction was limited to the lower esophageal sphincter, with both a hypertensive sphincter and impaired relaxation after swallows. Pharmacologic testing confirmed a mild abnormality of the inhibitory pathway to the LES with an intact excitatory pathway and sphincter muscle. This case suggests that amyloidosis, like idiopathic achalasia and carcinoma of the lower esophagus, can produce dysphagia by selective impairment of the inhibitory neural pathway to the lower esophageal sphincter.

Infarction of intestine with massive amyloid deposition in two patients on long-term hemodialysis

Two patients undergoing hemodialysis for 19 and 13 yr, respectively, developed intestinal infarction with extensive amyloid deposits in the muscle layer and blood vessels. In 1 patient the deposit reacted positively with antiserum to beta 2-microglobulin by immunohistochemical stain, and therefore was classified as beta 2-microglobulin in origin. The amyloid protein of the other patient remains unclassified. In patients with gastrointestinal symptoms who have been undergoing hemodialysis for long periods of time, amyloidosis of the intestine should be considered.

Massive macroglossia, amyloidosis and myeloma

A 74 year old man with light-chain myeloma developed amyloidosis with macroglossia after 10 years of therapy with alkylating agents. Over a 2-year period his tongue enlarged to persistently protrude from his mouth, inhibit his speech, interfere with normal swallowing and eventually threaten his airway. As a life-saving procedure the tumorous anterior two-thirds of the tongue was resected, with excellent primary healing. Within two weeks the patient's speech became comprehensible and his ability to eat returned to normal. Although rare in amyloidosis, massive macroglossia may occur and surgical correction is easily achieved.

AA amyloid-associated gastroenteropathy in a horse

Systemic amyloidosis involving the digestive tract is described in an 11-year-old Morgan stallion. The disease was characterized clinically by weight loss, ptyalism, anaemia, persistent mature neutrophilia, hypoalbuminaemia and hypergammaglobulinaemia. The D-xylose absorption test indicated malabsorption. Necropsy revealed oral, oesophageal and gastric ulcers and reddened segments of small bowel mucosa with scant haemorrhages. Microscopically, amyloid deposits were found throughout all tissue layers of the digestive tract, except the serosa. Deposits of amyloid were most apparent in the small bowel mucosa and submucosal arteries. Amyloid was also present in the spleen and lymph nodes and to a lesser extent in the liver, kidneys, lungs, pancreas and bone marrow. All amyloid deposits gave the typical histochemical reaction for AA amyloid with the KMnO4-Congo red stain procedure and immunohistochemical cross-reactivity was demonstrated with antisera to both canine and bovine protein AA by the peroxidase-antiperoxidase technique. The cause of the amyloidosis was not identified, although the haematological and serological data were compatible with an underlying chronic inflammatory process.

Vagus nerve and celiac ganglion lesions in generalized amyloidosis. A correlative study of familial amyloid polyneuropathy and AL-amyloidosis

To clarify the cause of gastrointestinal disorders in systemic amyloidosis we made pathologic and morphometric studies of vagus nerves, celiac ganglia, stomach and rectum in three autopsied cases with type 1 familial amyloid polyneuropathy (FAP) and two with nonhereditary generalized amyloidosis (AL-amyloidosis). The gastric and rectal walls in all cases were affected in the same way by amyloid deposition. On the other hand, there was a great difference between the two diseases in the severity of vagus nerve and celiac ganglion lesions: the vagus nerves in FAP showed very extensive endoneurial deposition of amyloid with severe loss of myelinated nerve fibers, but in AL-amyloidosis there was no loss of myelinated nerve fibers and only slight amyloid deposition in the endoneurium. Similarly, in the celiac ganglion, intraganglionic deposition of amyloid was prominent in FAP and slight in AL-amyloidosis. It is known that bowel symptoms frequently occur in type I FAP and are less prominent in AL-amyloidosis. This study demonstrated that the gastrointestinal autonomic nerves were more markedly disturbed by amyloid in the former than in the latter, and disorder in neural control of the digestive tract may be responsible for the bowel symptoms in systemic amyloidosis, especially in type I FAP.

An electron microscopic study on digestive tract amyloidosis in ferric nitrilotriacetate (Fe-NTA)-induced "F1 amyloidosis" mice

The histological distribution and ultrastructural findings were investigated in 52 amyloid-positive cases obtained from 80 F1 mice (32 males and 48 females) receiving 126 to 502 daily intraperitoneal injections of ferric nitrilotriacetic acid (Fe-NTA) resulting from reciprocal crossing of 20 parental mice receiving daily intraperitoneal injections of Fe-NTA for 5 months. Of 52 amyloidotic F1 mice 49 (94%) developed a moderate degree of amyloid deposits in the gastrointestinal tract. Moderate amounts of amyloid deposits were sporadically discernible in the lamina propria of the stomach pars glandularis, the duodenal mucosa, and to a lesser extent in that of the rectal mucosa. Electron microscopic observation revealed that macrophages adjacent to amyloid mass were radiating outward abundant bundles of non-branching amyloid fibrils from the cytoplasmic invaginations. In the cytoplasm of the macrophages there were occasionally acid phosphatase-positive lysosomes including amyloid fibrils measuring approximately 100 A in width. Moreover, it is discussed whether fibroblasts or fibroblast-like interstitial cells are involved in amyloid formation.

Gastrointestinal amyloid deposition in AL (primary or myeloma-associated) and AA (secondary) amyloidosis: diagnostic value of gastric biopsy

Gastrointestinal amyloid deposition was investigated in 21 autopsy cases of nonhereditary systemic amyloidosis, 18 of the AL (primary or myeloma-associated) type and three of the AA (secondary) type. Vascular deposition of amyloid, most apparent in the submucosa, was found in all cases. Parenchymal deposition was observed mainly in the muscularis mucosae and muscularis externa in the AL type, and in the lamina propria mucosae in the AA type. Comparison of amyloid deposition in the stomach and rectum revealed no differences for the AA type. In the AL type, however, deposition in the lamina propria mucosae and muscularis mucosae was more frequent and marked in the wall of the stomach than in the rectum. Thus, gastric biopsy would be more valuable than rectal biopsy in the diagnosis of AL amyloidosis.

Esophageal manometry in familial amyloid polyneuropathy

The motility of the esophagus was studied by esophageal manometry in eight patients with familial amyloid polyneuropathy. All eight patients had an abnormality of the lower esophageal sphincter. Seven of eight had a borderline or decreased lower esophageal sphincter pressure and the other patient had a non-relaxing lower esophageal sphincter pressure. Six of eight patients had abnormalities of the body of the esophagus consisting of either simultaneous or decreased amplitude of contractions involving the smooth or striated muscle or both. In addition, seven of eight patients had diarrhea and six of these seven patients had evidence for steatorrhea. The manometric abnormalities observed were consistent with deposition of amyloid in smooth and striated muscle as well as in the enteric nervous system. Esophageal manometry appears to be a sensitive technique to determine if the gastrointestinal tract is involved in familial amyloid polyneuropathy.

Secondary amyloidosis of the gastrointestinal tract: an electron microscopic study

Biopsy specimens of the gastric antrum, duodenum, and rectum from three patients with secondary amyloidosis were examined by electron microscopy in an attempt to determine the ultrastructural distribution of amyloid filaments and to identify any secondary changes in the covering mucosal epithelial cells. The characteristic amyloid filaments were seen in the walls of submucosal arterioles and mucosal capillaries deposited within the basal lamina surrounding the endothelial cells. Filaments were also sometimes seen within the muscularis mucosa. the overlying gastric and rectal epithelial cells appeared normal, but numerous curved bacilli were seen in close contact with the microvilli of the surface epithelial gastric cells. Duodenal columnar absorptive cells were vacuolated and contained prominent lysosomes. These changes are probably degenerative and may explain, at least in part, the development of malabsorption in some patients with intestinal amyloidosis.

Esophageal manometry in systemic amyloidosis. A study of 30 patients

The motility of the esophagus was studied by esophageal manometry in 24 patients with primary amyloidosis and six with secondary amyloidosis. Resting lower esophageal sphincter pressure was decreased in 12 patients with primary amyloidosis and two with secondary amyloidosis; 12 of these 14 patients complained of heartburn. Abnormalities in the motility of the body of the esophagus were found in nine patients with primary amyloidosis and one with secondary amyloidosis. No abnormality of the upper esophageal sphincter was demonstrated in any of the 30 patients. Six of the nine patients with primary amyloidosis exhibiting the most marked esophageal motor dysfunction had striking evidence of peripheral and/or autonomic nervous system involvement. No consistent pattern of motility disorder was observed in either group. The manometric abnormalities observed are consistent with a random deposition of amyloid in the esophagus involving a myopathic and/or neuropathic component.

Relationship between morphological findings and function of the small intestine in familial amyloidosis with polyneuropathy

Twenty-seven patients with familial amyloidosis with polyneuropathy were studied with regard to the morphology of the small intestine, and this was correlated to symptoms and malabsorption features. The mucosa was normal in all cases investigated by the dissecting microscope, the light microscope, and the scanning electron microscope. Amyloid was demonstrated in 83% of the cases by the presence of green birefringent material in the biopsy specimens stained with alkaline Congo red and examined in polarized light. Nineteen patients had steatorrhea, and 12 had pathological D-xylose test results. The degree of amyloid infiltration did not correlate with these data, nor did the symptomatic state correlate with the amount of amyloid in the biopsy specimens. The surface ultrastructure was normal when investigated by means of the scanning electron microscope in all patients except five in whom the glycocalyx was altered. As a group, however, those five did not differ in any respect from the rest of the patients. Rod-shaped microorganisms were shown to adhere to the surface in one patient. The results suggest that mechanisms other than bowel-wall deposition of amyloid cause the dysfunction of the gastrointestinal tract in familial amyloid polyneuropathy.

Achalasia-like esophagus from amyloidosis. Successful treatment with pneumatic bag dilatation

A 78-year-old man with amyloidosis involving the esophagus is described. The clinical and radiographic features resembled classic achalasia, while esophageal manometrics demonstrated aperistalsis, incomplete LES relaxation, but a normal LES resting pressure. A review of the literature suggests that esophageal amyloid may have variable presentations. This patient was successfully managed with forceful pneumatic bag dilatation.

Gastroscopic biopsy of the stomach for the diagnosis of amyloidosis

1. Amyloid deposition was investigated in the biopsied specimens obtained from the stomachs of suspected cases of amyloidosis. The subjects were seven cases of suggestive amyloidosis with clinical symptoms of muscle rigidity, masked face, macroglossia and B-J proteinuria. The stomach of an autopsied amyloidosis patient was also investigated. 2. Mucosal tissue was obtained from fundus, corpus and antrum of the stomach using gastrofiberscope, Olympus GFB2. And amyloid in the tissue was detected by H & E Congo red staining and polarization microscopy. Rectal biopsy was also done in the majority of the cases to compare with stomach biopsy. 3. Positive results were obtained with gastric biopsy in all seven cases and five of the 5 cases by rectal biopsy. Thus, gastric and rectal biopsy yielded the same results so far as detection of amyloid deposition was concerned. 4. Biopsy specimens from several sites of the stomach gave similar results in regard to the amyloid deposition. Tissue deposition of amyloid in the stomach wall showed a somewhat high incidence in the walls of intramucosal capillaries and in the walls of blood vessels of lamina muscularies mucosa. Gastroscopic biopsy of the stomach proved to be useful as a routine technique for the definite diagnosis of the disease.

Amyloid colitis

Amyloidosis not infrequently involves the gastrointestinal tract and may result in a variety of symptoms, including those related to impaired motility, malabsorption, and ulceration due to ischemia. This report describes the case of a 74-year-old man with systemic amyloidosis secondary to multiple myeloma, with striking gross morphologic findings involving the colon, seen at autopsy, resembling severe inflammatory bowel disease. Microscopically, the small arterioles of the lamina propria were markedly narrowed or occluded by massive deposition of amyloid, presumably leading to diffuse ischemia and mucosal necrosis. Although the radiologic appearance of this condition has been well recognized, and ischemia due to amyloidosis has been described, this case is presented to demonstrate the gross anatomic changes not illustrated in previous reviews of the subject.

Gastrointestinal amyloidosis complicating psoriatic arthropathy

A patient is described who developed gastrointestinal amyloidosis complicating psoriatic arthropathy. The presenting symptom was progressive dysphagia due to oesophageal involvement. Other clinical features included gastric ulceration with melaena, intestinal pseudo-obstruction and evidence of impaired renal function. The oesophageal symptoms improved after endoscopic dilatation of the cardia. Colchicine was used in an attempt to slow down progression of the condition.

Amyloidosis and chronic intestinal pseudoobstruction

A 39-year-old woman with multiple myeloma developed chronic intestinal pseudoobstruction associated with gastrointestinal amyloidosis. Motor abnormalities of the lower esophageal and anal sphincters correlated closely with amyloid infiltration in affected areas. Manometric abnormalities of esophageal and anal sphincter function may provide indirect evidence of amyloid deposition of gastrointestinal smooth muscle in an appropriate clinical setting.

Deposition of amyloid in the gastrointestinal tract

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