Deposition of amyloid in the gastrointestinal tract

Disorders of gastrointestinal motility in neurologic diseases

Neurologic diseases can affect the bowel at several levels of innervation--by altering the electrical activity that controls smooth muscle, the enteric nervous system, or the extrinsic neural pathways to the gut. This review concentrates on disorders of motility that occur in conjunction with diseases of the extrinsic neural supply (from the level of the brain to the postganglionic fibers) and those generalized disorders that affect gut smooth muscle. Modern technology, such as gastrointestinal scintigraphy and manometric techniques that measure esophageal, gastroduodenal, and anorectal motility (intraluminal pressures), has provided better methods to study the pathophysiologic aspects of gut motility in diseases of the nervous system. Distinguishing the neuropathies of the extrinsic nervous system from those of the intrinsic (enteric) nervous system is not always possible because the available techniques evaluate only the end-organ--that is, the motor function of the gut. Degenerative or infiltrative (myopathic) disorders of gut smooth muscle, however, can be distinguished from such neuropathies, and careful and systematic evaluation of autonomic function can often identify the level of disordered function in the neural-gut axis.

Endoscopic and biopsy findings of the upper digestive tract in patients with amyloidosis

Endoscopic and biopsy findings of the esophagus, stomach, duodenum, and colorectum were studied in 37 patients with amyloidosis involving the gastrointestinal tract. Endoscopic examinations revealed fine granular appearance, polypoid protrusions, erosions, ulcerations, and mucosal friability in many cases. These findings were most marked and noticed most often in the second portion of the duodenum. The frequency of amyloid deposition in the biopsy specimens was as follows; 100% in the duodenum, 95% in the stomach, 91% in the colorectum, and 72% in the esophagus. The degree of amyloid deposition in the duodenum, which was the highest of the entire gastrointestinal tract, significantly correlated with the frequency of endoscopic findings such as fine granular appearance and polypoid protrusions. Therefore, the two endoscopic findings described above are characteristic of this disease and may reflect amyloid deposition in the mucosa or submucosa of the alimentary tract. Our results indicate that for a diagnosis of amyloidosis, it is important to examine the upper gastrointestinal tract, especially the duodenum, using endoscopy and biopsy techniques.

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.

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.

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.

Surgical complications of amyloid disease

The case of a man with primary systemic amyloidosis without myelomatosis and long-term survival is described. The patient has had major surgical complications from large amyloid deposits in the colon, dorsal spine and peritoneal cavity. The patient remains well 14 years after diagnosis.

A case of primary amyloidosis confined to the small intestine

A 60 year-old man with primary amyloidosis confined to the small intestine was reported. Multiple polyps of the small intestine were found by an upper GI series and enteroscopic polypectomy revealed massive deposition of amyloid in the lamina propria and the submucosa. No predisposing disorder or other sites of deposition were found, and the diagnosis of primary amyloidosis of the small intestine was confirmed.

The incidence of amyloidosis complicating inflammatory bowel disease. A prospective survey of 177 patients

Three cases of secondary amyloidosis are reported, two in patients who had unequivocal Crohn's disease and one in whom the clinical course was that of Crohn's disease, but with histologic findings that were more suggestive of ulcerative colitis. All had evidence of renal failure. A prospective study of 177 patients with inflammatory bowel disease of greater than five years' duration was carried out in an attempt to establish the incidence of secondary amyloidosis, using rectal biopsy and simple renal function tests. No new cases were found. Neither was there evidence of renal failure due to other conditions. In the absence of renal dysfunction, a search for secondary amyloidosis probably is not justified.

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.

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.

Improvement of endoscopic and histologic findings of AA-type gastrointestinal amyloidosis by treatment with dimethyl sulfoxide and prednisolone

We report the successful treatment of gastrointestinal amyloidosis with dimethyl sulfoxide. A 37 year-old man with adult-onset Still's disease suffered from diarrhea. Upper and lower gastrointestinal endoscopy revealed edematous mucosa, white patches, erosions and bleeding and amyloid deposits were demonstrated in biopsy specimens. After a period of 3 months dimethyl sulfoxide and prednisolone therapy, improvement in the endoscopic appearance of the gastrointestinal tract was observed. Amyloid deposits in biopsy specimens were reduced in the stomach and negative in the large intestine.

Sulfasalazine in treatment of collagenous colitis. Case report and review of the literature

A patient is described with chronic colitis, watery diarrhea, and colonic mucosal subepithelial collagen deposition that resolved while being treated with sulfasalazine. The clinicopathologic features were consistent with collagenous colitis. Theoretically, the thickened collagen layer impairs water and electrolyte absorption, producing watery diarrhea. Such increased collagen is rarely observed in other inflammatory colon diseases and may represent a distinct morphologic reaction to various, yet undefined, injuries. Although the clinical course is benign, appropriate therapy for the debilitating symptoms is poorly understood. This report suggests that sulfasalazine may be helpful in some cases.

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.

Amyloidosis of the colon. Report of a case and review of the literature

A case of amyloidosis of the colon associated with multiple myeloma is presented. The unusual situation was that of obstructive signs with radiologic features of "megacolon and volvulus." A high index of suspicion and meticulous histologic search will demonstrate involvement of the gastrointestinal tract in 98 per cent of patients with systemic amyloidosis. Amyloidosis may mimic other gastrointestinal disorders. Rectal biopsy is diagnostic in 75 per cent of the patients. Treatment of amyloidosis of the colon involves treating the cause with the hope of reversing or at least retarding the process. The results of treatment based on the available experience have been dismal.

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.

Nutritional evaluation of hemodialysis patients with and without spinal cord injury

Both end stage renal disease (ESRD) and spinal cord injury (SCI) represent major disabling conditions that may be associated with protein-calorie malnutrition (PCM). The prevalence of PCM in ESRD, however, remains unknown, and virtually no data exist regarding the status of PCM in patients with both SCI and ESRD. In this study we evaluated 23 ambulatory-ESRD patients and 11 SCI-ESRD patients utilizing a range of parameters recommended for assessing nutritional status in ESRD. Based on these parameters, our results show evidence for PCM in a substantial proportion of both groups. When the two groups were compared, however, the frequency and severity of PCM were significantly greater in the SCI-ESRD patients. Important factors felt to adversely influence nutritional status in the SCI-ESRD patients were intercurrent infection and amyloidosis that were found to frequently complicate this setting. It is also probable that the combined effects of PCM and ESRD significantly predispose these patients to further infection, establishing a vicious cycle.

Gastrointestinal effects of long-term colchicine therapy in patients with recurrent polyserositis (familial mediterranean fever)

Twelve patients with recurrent polyserositis (RP, familial Mediterranean fever) on colchicine prophylaxis (1.0-2.0 mg daily) for three years or more were evaluated for the presence of gastrointestinal effects possibly attributable to the drug. Two patients had bulky stools, two others had transient diarrhea, and one had heartburn. Serum vitamin B12, calcium, and carotene levels were normal in all cases, and D-xylose absorption was normal in 11 of the 12. Three patients had mild steatorrhea (7.5, 7.9, and 9.9 g daily). Jejunal biopsies from these and a fourth patient with bulky stools but normal fecal fat excretion showed no abnormal histological changes. However, (Na + K)-ATPase activity was significantly decreased in all four cases. Colchicine had to be discontinued in only one of the 12 cases. It is concluded that mild steatorrhea and enzyme inhibition may occur in patients on long-term colchicine prophylaxis and that careful periodic observations for this and other adverse effects is imperative in such patients.

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.

Collagenous colitis: an unrecognised entity

A patient is reported with chronic abdominal pain, diarrhoea, and associated radiological and endoscopic abnormalities of the sigmoid colon. Light and electron microscopic study of colorectal mucosa showed abnormal collagenous thickening of the subepithelial basement membrane. The authors felt that the clinical and morphological features justified a diagnosis of collagenous colitis. Review of the literature suggested that collagenous colitis was still an unrecognised entity.

Amyloidoma of the stomach

Localized amyloid deposit in the gastric antrum presented as an ulcerated mass on upper gastrointestinal series. Radiographic and autopsy findings are correlated and the literature is reviewed.

Protein-losing enteropathy due to gastro-intestinal amyloidosis

A case is described of a patient who presented with severe oedema due to protein-losing enteropathy caused by amyloidosis secondary to bronchiectasis.

Intestinal pseudo-obstruction in systemic amyloidosis

The occurrence of clinical manifestations of mechanical intestinal obstruction in eight cases of systemic amyloidosis is reported. Seven similar cases have been recorded in the literature and are briefly reviewed. Correct diagnosis is important in these cases if useless surgical treatment or prolonged diagnostic investigations are to be avoided. Gastrointestinal involvement by systemic amyloidosis should be considered in a patient presenting with clinical manifestations of mechanical obstruction but paralytic ileus seen on plain films. In these cases an attempt should be made, by means of a barium enema, to exclude an obstructing lesion of the colon or distal small bowel. Once amyloidosis is considered, it can be confirmed easily and safely by biopsy of the rectal or small-intestinal mucosa.