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Mauermann ML, Clarke JO, Litchy WJ, Obici L, Lousada I, Gertz MA. Peripheral Nervous, Hepatic, and Gastrointestinal Endpoints for AL Amyloidosis Clinical Trials: Report from the Amyloidosis Forum Multi-organ System Working Group. Adv Ther 2023; 40:4695-4710. [PMID: 37658177 PMCID: PMC10567953 DOI: 10.1007/s12325-023-02637-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/03/2023] [Indexed: 09/03/2023]
Abstract
Systemic immunoglobulin light chain (AL) amyloidosis is a heterogeneous rare disease driven by a destructive monoclonal gammopathy and typified by misfolded immunoglobulin light and/or heavy chains which aggregate and deposit in organs as insoluble amyloid fibrils. Disease heterogeneity is driven by the degree of multi-systemic involvement; cardiac, renal, neurological, and gastrointestinal (GI) systems are affected to varying degrees in different patients. While prognosis is primarily driven by hematologic response to treatment and outcomes associated with cardiac events and overall survival, the involvement of the peripheral nervous, hepatic, and GI systems can also have a significant impact on patients. The Amyloidosis Forum ( https://amyloidosisforum.org ) is a public-private partnership between the nonprofit Amyloidosis Research Consortium ( www.arci.org ) and the US Food and Drug Administration (FDA) Center for Drug Evaluation and Research formed to advance drug development for the treatment of systemic amyloid disorders. A series of virtual workshops focused on the development of novel, patient-relevant endpoint components and analytical strategies for clinical trials in AL amyloidosis. This review summarizes the proceedings and recommendations of the Multi-Systemic Working Group which identified, reviewed, and prioritized endpoints relevant to the impacts of AL amyloidosis on the peripheral nervous, hepatic, and GI systems. The Working Group comprised amyloidosis experts, patient representatives, statisticians, and representatives from the FDA, Medicines and Healthcare products Regulatory Agency (MHRA), and pharmaceutical companies. Prioritized neuropathy/autonomic endpoints included a modified form of the Neuropathy Impairment Score (NIS + 7) and the Composite Autonomic Symptom Score (COMPASS-31), respectively. Alkaline phosphatase was identified as the most relevant indicator of liver involvement and disease progression. Following extensive review of potential GI endpoints, the Working Group identified multiple exploratory endpoints. These recommended components will be further explored through evaluation of clinical trial datasets and possible integration into composite endpoint analysis.
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Affiliation(s)
| | | | | | - Laura Obici
- University of Pavia, IRCCS University Hospital Policlinico San Matteo, Pavia, Italy
| | - Isabelle Lousada
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA.
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Ream S, Ma J, Rodriguez T, Sarabia-Gonzalez A, Alvarado LA, Dwivedi AK, Mukherjee D. Ethnic/racial differences in risk factors and clinical outcomes among patients with amyloidosis. Am J Med Sci 2023; 365:232-241. [PMID: 36543303 DOI: 10.1016/j.amjms.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/21/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cardiac amyloidosis is caused by abnormal extracellular deposition of insoluble fibrils in cardiac tissue. It can be fatal when untreated and is often underdiagnosed. Understanding the ethnic/racial differences in risk factors is critical for early diagnosis and treatment to improve clinical outcomes. METHODS We performed a retrospective cross-sectional study utilizing the National Inpatient Sample database from 2015 to 2018 using ICD-10-CM codes. The primary variables of interest were race/ethnicity and amyloidosis subtypes, while the primary outcomes were in-hospital mortality, gastrointestinal bleeding, renal failure, and hospital length-of-stay. RESULTS Amyloidosis was reported in 0.17% of all hospitalizations (N = 19,678,415). Of these, 0.09% were non-Hispanic whites, 0.04% were non-Hispanic blacks, and 0.02% were Hispanic. Hospitalizations with ATTR amyloidosis subtype were frequently observed in older individuals and males with coronary artery disease, whereas AL amyloidosis subtype was associated with non-Hispanic whites, congestive heart failure, and longer hospital length of stay. Renal failure was associated with non-Hispanic blacks (adjusted relative risk [RR] = 1.31, p < 0.001), Hispanics (RR = 1.08, p = 0.028) and had an increased risk of mortality. Similarly, the hospital length of stay was longer with non-Hispanic blacks (RR = 1.19, p < 0.001) and Hispanics (RR = 1.05, p = 0.03) compared to non-Hispanic whites. Hispanics had a reduced risk of mortality (RR = 0.77, p = 0.028) compared to non-Hispanic whites and non-Hispanic blacks, and no significant difference in mortality was seen between non-Hispanic whites and non-Hispanic blacks (RR = 1.00, p = 0.963). CONCLUSIONS Our findings highlight significant ethnic/racial differences in risk factors and outcomes among amyloidosis-related US hospitalizations that can possibly be used for early detection, treatment, and better clinical outcomes.
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Affiliation(s)
- Sarah Ream
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Jennifer Ma
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Tayana Rodriguez
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Alejandro Sarabia-Gonzalez
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Luis A Alvarado
- Biostatitsics and Epidemiology Consulting Lab (BECL), Office of Research, Texas Tech University of Health Sciences Center, El Paso, TX, United States
| | - Alok Kumar Dwivedi
- Biostatitsics and Epidemiology Consulting Lab (BECL), Office of Research, Texas Tech University of Health Sciences Center, El Paso, TX, United States; Department of Molecular and Translational Medicine, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX, United States
| | - Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Sciences Center at El Paso, TX, United States.
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Ussia A, Vaccari S, Lauro A, Caira A, Tardio ML, Leone O, Marino IR, D'Andrea V, Cervellera M, Tonini V. Colonic Perforation as Initial Presentation of Amyloid Disease: Case Report and Literature Review. Dig Dis Sci 2020; 65:391-398. [PMID: 31728786 DOI: 10.1007/s10620-019-05948-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Amyloidosis is an uncommon disease caused by the deposition of amyloid fibrils in tissues. This disease does not usually require surgical intervention, which could be warranted in the presence of complications such as bleeding, obstruction, or perforation. We present a case of primary amyloidosis of the colon in a patient affected by polymyositis who underwent Hartmann's procedure after a spontaneous colonic perforation. After 2 months of well-being, the patient underwent two consecutive surgical procedures for stenosis of the ostomy orifice. AREAS COVERED A review of the literature has been performed, gathering case reports highlighting the distribution of this disease by age, gender, location, and treatment when available. EXPERT COMMENTARY Gastrointestinal amyloid disease is a rare condition, and it could be considered among the rare causes of intestinal perforation. Timely surgical management is often necessary.
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Affiliation(s)
- A Ussia
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
| | - S Vaccari
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
| | - A Lauro
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy.
| | - A Caira
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
| | - M L Tardio
- Department of Pathology, St. Orsola University Hospital, Bologna, Italy
| | - O Leone
- Department of Pathology, St. Orsola University Hospital, Bologna, Italy
| | - I R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - V D'Andrea
- Department of Surgical Sciences, La Sapienza University, Umberto I Hospital, Rome, Italy
| | - M Cervellera
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
| | - V Tonini
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
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den Braber-Ymker M, Heijker S, Lammens M, Croockewit S, Nagtegaal ID. Intestinal involvement in amyloidosis is a sequential process. Neurogastroenterol Motil 2018; 30:e13469. [PMID: 30230124 DOI: 10.1111/nmo.13469] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gastrointestinal amyloidosis causes dysmotility. A comprehensive histological analysis to explain these symptoms is lacking. Therefore, we systematically examined histological features of intestinal dysmotility in patients with AL and AA amyloidosis, compared to controls. METHODS Autopsy tissue material from small bowel and colon was used for histological (semiquantitative) evaluation of the mucosa, blood vessels, muscular layers, enteric nervous system (ENS) and the interstitial cells of Cajal (ICC), using hematoxylin and eosin, periodic acid Schiff, Elastic von Gieson and Congo red staining, and immunohistochemistry with α-smooth muscle actin, HuC/D, S100 and CD117 antibodies, according to guidelines of the Gastro 2009 International Working Group. KEY RESULTS Amyloid deposits were present in the vascular walls of all amyloidosis patients. In the mucosa, amyloid was found in 67% of AA patients. The muscular layers were involved in 64% of amyloidosis patients, most prominent in AA patients, associated with the presence of polyglucosan inclusion bodies, but not with either abnormal α-actin patterns or fibrosis. Amyloid in the muscularis propria surrounding the myenteric plexus was found, but not inside the myenteric plexus. These deposits might be related to loss of the ICC network, but there was no association with decreased neuronal or nerve fiber density. CONCLUSIONS & INFERENCES We hypothesize that intestinal dysmotility in amyloidosis patients is a sequential process: amyloid deposition starts in the vasculature, followed by involvement of the muscular layers, ICC loss, and potentially affect the myenteric plexus. This final stage may be accompanied by clinical symptoms of severe intestinal dysmotility.
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Affiliation(s)
| | - Sanneke Heijker
- Department of Pathology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Martin Lammens
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Pathology, Antwerp University Hospital, University of Antwerp, Edegem, Belgium.,MIPRO, University of Antwerp, Antwerp, Belgium
| | - Sandra Croockewit
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
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Shaulov A, Avivi I, Cohen Y, Duek A, Leiba M, Gatt ME. Gastrointestinal perforation in light chain amyloidosis in the era of novel agent therapy - a case series and review of the literature. Amyloid 2018; 25:11-17. [PMID: 29241368 DOI: 10.1080/13506129.2017.1416350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Gastrointestinal (GI) perforation is remarkably rare in patients with light chain (AL) amyloidosis and has not yet been reported in patients with AL amyloidosis treated with novel agents. Only 24 cases of GI perforation have previously been reported in the setting of AL amyloidosis of which 15 had available information in English. All 15 did not receive novel agent therapy and six died early after experiencing GI perforation. This study reports the characteristics and outcome of AL patients that developed GI perforation in the era of novel agent treatment. Seven patients were reviewed. In two patients, GI perforation was the presenting symptom of AL amyloidosis, whereas five patients developed GI perforations following initiation of an anti-AL therapy (three after bortezomib-based, 1 after lenalidomide-based and 1 after thalidomide-based therapy). All patients underwent surgery and survived the perforation. Treatment was renewed following surgery in six of seven patients, with no further GI complications. In conclusion, GI perforation in AL amyloidosis is rare and mostly reported after treatment initiation. Urgent surgery appears to be lifesaving and renewal of the anti-AL novel therapy appears to be safe, with no significant risk for re-perforation or GI toxicity. Prognosis in these patients is related to severity of the disease and response to therapy rather than the development of GI perforation.
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Affiliation(s)
- Adir Shaulov
- a Department of Haematology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Irit Avivi
- b Department of Haematology and Bone Marrow Transplantation , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel
| | - Yael Cohen
- b Department of Haematology and Bone Marrow Transplantation , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel
| | - Adrian Duek
- c Department of Haematology , Sheba-Tel HaShomer Medical Center , Tel Aviv , Israel
| | - Merav Leiba
- c Department of Haematology , Sheba-Tel HaShomer Medical Center , Tel Aviv , Israel
| | - Moshe E Gatt
- a Department of Haematology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
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Chan C, Lam K. Amyloidosis at the Ampulla of Vater and Recurrent Pyogenic Cholangitis: Cause or Effect? J R Soc Med 2018; 74:310-2. [PMID: 7230245 PMCID: PMC1438363 DOI: 10.1177/014107688107400415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Amyloidosis of the gastrointestinal tract and the liver: clinical context, diagnosis and management. Eur J Gastroenterol Hepatol 2016; 28:1109-21. [PMID: 27362550 DOI: 10.1097/meg.0000000000000695] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Amyloidosis is a group of disorders that can manifest in virtually any organ system in the body and is thought to be secondary to misfolding of extracellular proteins with subsequent deposition in tissues. The precursor protein that is produced in excess defines the specific amyloid type. This requires histopathological confirmation using Congo red dye with its characteristic demonstration of green birefringence under cross-polarized light. Gastrointestinal (GI) manifestations are common and the degree of organ involvement dictates the symptoms that a patient will experience. The small intestine usually has the most amyloid deposition within the GI tract. Patients generally have nonspecific findings such as abdominal pain, nausea, diarrhea, and dysphagia that can often delay the proper diagnosis. Liver involvement is seen in a majority of patients, although symptoms typically are not appreciated unless there is significant hepatic amyloid deposition. Pancreatic involvement is usually from local amyloid deposition that can lead to type 2 diabetes mellitus. In addition, patients may undergo either endoscopic or radiological evaluation; however, these findings are usually nonspecific. Management of GI amyloidosis primarily aims to treat the underlying amyloid type with supportive measures to alleviate specific GI symptoms. Liver transplant is found to have positive outcomes, especially in patients with specific variants of hereditary amyloidosis.
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Kent TH, Moon HW. The Comparative Pathogenesis of Some Enteric Diseases. Based on Cases Presented at the 22nd Annual Seminar of the American College of Veterinary Pathologists. Vet Pathol 2016. [DOI: 10.1177/030098587301000506] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Basic reactions of the intestinal tract to injury are discussed using cases presented at the American College of Veterinary Pathologists' Seminar on Intestinal Pathology. Reports of the individual cases are cited in the text. Material reported during discussions is presented to preserve something of the tenor of the Seminar. First, the morphogenesis of the lesions in each case will be discussed, followed by the resultant functional changes related to clinical signs, and comparisons to other similar diseases.
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Affiliation(s)
- T. H. Kent
- Department of Pathology, College of Medicine, University of Iowa, Iowa City; and The National Animal Disease Laboratory, North Central Region, Agricultural Research Service, U. S. Department of Agriculture, Ames, Iowa
| | - H. W. Moon
- Department of Pathology, College of Medicine, University of Iowa, Iowa City; and The National Animal Disease Laboratory, North Central Region, Agricultural Research Service, U. S. Department of Agriculture, Ames, Iowa
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Abstract
Amyloidosis often involves the gastrointestinal tract. The small intestine is the most commonly involved gastrointestinal site. Gastrointestinal manifestations of amyloidosis involvement of the small intestine include diarrhea, gastrointestinal bleeding, and obstruction. High index of suspicion leading to early diagnosis is important in tailoring appropriate therapeutic management of these patients.
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Kim SY, Moon SB, Lee SK, Hong SK, Kim YH, Chae GB, Park SB. Light-chain amyloidosis presenting with rapidly progressive submucosal hemorrhage of the stomach. Asian J Surg 2013; 39:113-5. [PMID: 24246158 DOI: 10.1016/j.asjsur.2013.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022] Open
Abstract
The gastrointestinal tract is frequently in involved light-chain (AL) amyloidosis, but significant hemorrhagic complications are rare. A 71-year-old man presented to our hospital with dyspepsia and heartburn for 1 month. Gastroscopy revealed a large submucosal hematoma at the gastric fundus. Two days later, a follow-up gastroscopy indicated extensive expansion of the hematoma throughout the upper half of the stomach. The hematoma displayed ongoing expansion during the endoscopic examination, suggesting that rupture was imminent. Emergency total gastrectomy was performed, and amyloidosis was confirmed after examining the surgical specimen. Bone marrow examination revealed multiple myeloma, and serum immunoglobulin assay confirmed the diagnosis of myeloma-associated AL amyloidosis. At manuscript submission, the patient was doing well and was undergoing chemotherapy.
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Affiliation(s)
- Song-Yi Kim
- Department of Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Suk-Bae Moon
- Department of Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Seung Koo Lee
- Department of Pathology, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Seong Kweon Hong
- Department of Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Yang Hee Kim
- Department of Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Gi Bong Chae
- Department of Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Sung-Bae Park
- Department of Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, South Korea.
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[Pancreas-preserving duodenal-jejunal resection due to complicated intestinal amyloidosis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:268-70. [PMID: 23369620 DOI: 10.1016/j.gastrohep.2013.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Accepted: 11/06/2012] [Indexed: 11/21/2022]
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Abstract
Gastroparesis is a prevalent condition that produces symptoms of delayed gastric emptying in the absence of physical blockage. The most common etiologies of gastroparesis are idiopathic, diabetic, and postsurgical disease, although some cases stem from autoimmune, paraneoplastic, neurologic or other conditions. Histologic examination of gastric tissues from patients with severe gastroparesis reveals heterogeneous and inconsistent defects in the morphology of enteric neurons, smooth muscle and interstitial cells of Cajal, and increased levels of inflammatory cells. Diagnosis is most commonly made by gastric emptying scintigraphy; however, wireless motility capsules and nonradioactive isotope breath tests have also been validated. A range of treatments have been used for gastroparesis including dietary modifications and nutritional supplements, gastric motor stimulatory or antiemetic medications, endoscopic or surgical procedures, and psychological interventions. Most treatments have not been subjected to controlled testing in patients with gastroparesis. The natural history of this condition is poorly understood. Active ongoing research is providing important insights into the pathogenesis, diagnosis, treatment and outcomes of this disease.
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Affiliation(s)
- William L Hasler
- Division of Gastroenterology, University of Michigan Hospital, 3912 Taubman Center, Ann Arbor, MI 5362, USA.
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Perforation of rectal diverticulum with amyloidosis secondary to rheumatoid arthritis: case report and review of the literature. Clin J Gastroenterol 2009; 3:30-5. [DOI: 10.1007/s12328-009-0132-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Accepted: 11/22/2009] [Indexed: 10/20/2022]
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Abstract
Amyloidosis is characterized by the extracellular deposition of an abnormal fibrillar protein, which disrupts tissue structure and function. Amyloid may be localized to a single organ, such as the GI tract, or be systemic where the amyloid type is defined by the respective fibril precursor protein. Among patients with systemic amyloidosis, histological involvement of the gastrointestinal (GI) tract is very common but often subclinical. The presence and pattern of GI symptoms varies substantially, not only between the different amyloid types but also within them. GI presentations are frequently nonspecific and include macroglossia, dyspepsia, hemorrhage, a change in bowel habit and malabsorption. Endoscopic and radiological features of amyloidosis are also nonspecific, with the small intestine most commonly affected. In the absence of specific treatments for GI amyloidosis, therapy is aimed at reducing or eliminating the supply of the respective fibril precursor protein. Supportive measures such as nutritional support and antidiarrheal agents should be instigated while awaiting the clinical improvement associated with a successful reduction in the abundance of the fibril precursor protein. GI tract surgery should be performed only if the benefits clearly outweigh the risks, as there is a risk of decompensation of organs affected by amyloid.
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Affiliation(s)
- Prayman Sattianayagam
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, UCL Medical School, Royal Free Hospital Campus, Rowland Hill Street, London NW3 2PF, UK
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Abstract
OBJECTIVE Immunoglobulin light-chain (AL) amyloidosis is a rare disease that can affect several organs. The aim of this study was to characterize patients with gastrointestinal manifestations of AL amyloidosis, in terms of symptoms, biochemistry, and outcome. MATERIAL AND METHODS Retrospectively, patients with AL amyloidosis admitted for evaluation of malabsorption in a Department of Gastroenterology between January 2000 and December 2006 were identified. RESULTS A total of 11 patients (4 F, age 60 years, median (range) 50-69) were included in the study. Gastrointestinal amyloidosis was histologically verified in all patients. All patients had gastrointestinal symptoms, 8 of them prior to establishment of diagnosis. Median (range) delay from initial symptoms to diagnosis was 7 (0-24) months. The most prominent symptom was weight loss (n=10) averaging 7 (0-25) kg, followed by diarrhea (n=5). Steatorrhea (2 mild, 1 moderate, 1 severe) was found in 4 of 7 patients examined. At presentation, 9 patients had hypoalbuminemia and 6 patients had anemia. Three patients were treated with home parenteral nutrition. Five patients received conventional chemotherapy (oral melphalan and prednisone) and 5 patients underwent high-dose melphalan and autologous stem-cell transplantation. Five patients died within the observation period, at a median of 10 (3-36) months after the diagnosis was established. Non-survivors tended to have lower albumin levels on admission and more involvement of other organs compared to survivors. CONCLUSIONS Most patients with gastrointestinal AL amyloidosis experience weight loss and all have signs of malabsorption. Despite treatment the prognosis is grave.
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Sattianayagam PT, Hawkins PN, Gillmore JD. Systemic amyloidosis and the gastrointestinal tract. Nat Rev Gastroenterol Hepatol 2009; 6:608-17. [PMID: 19724253 DOI: 10.1038/nrgastro.2009.147] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Systemic amyloidosis is characterized by the extracellular deposition of protein in an abnormal fibrillar form. Several different types of amyloidosis exist, each defined by the identity of their respective fibril precursor protein. Among patients with systemic amyloidosis, histological involvement of the gastrointestinal tract is very common but is often subclinical. Conversely, primary diseases of the gastrointestinal tract can cause systemic amyloidosis; for example, AA amyloidosis can occur secondary to IBD. The presence and pattern of gastrointestinal symptoms varies substantially, not only between the different types of amyloidosis but also within them. Typical clinical presentations, most of which are nonspecific, include macroglossia, hemorrhage, motility disorders, disturbance of bowel habit and malabsorption. Endoscopic and radiological features are also nonspecific, with the small intestine most commonly affected. Currently, the aim of therapy for amyloidosis is to slow amyloid formation by reducing the abundance of the fibril precursor protein. No specific treatments for the gastrointestinal symptoms of systemic amyloidosis are available; however, case reports and small published series encourage nutritional support for patients with motility disorders and pharmacological agents for treatment of diarrhea. Surgical procedures should be contemplated only in an emergency setting because of the risk of decompensation of organs affected by amyloid deposition.
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Affiliation(s)
- Prayman T Sattianayagam
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine (Royal Free Campus), University College London Medical School, London, UK
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Funch-Jensen P, Foged E, Ravnsbaek J, Søgaard H. A case of esophageal spasms in amyloidosis. ACTA MEDICA SCANDINAVICA 2009; 219:229-33. [PMID: 3962736 DOI: 10.1111/j.0954-6820.1986.tb03303.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Impairment of esophageal peristalsis in amyloidosis is well known. A patient in whom esophageal spasms and orocricopharyngeal dyscoordination accompanied myeloma-associated amyloidosis is presented below. The different possible mechanisms producing these abnormalities are discussed.
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Basavaraju KP, Mansour D, Barnes S, Whitehead MW, Bruce SA. A rare cause of dysphagia and gastroparesis. BMJ Case Rep 2009; 2009:bcr07.2008.0358. [PMID: 21686844 PMCID: PMC3027495 DOI: 10.1136/bcr.07.2008.0358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An 82-year-old woman was admitted with severe vomiting and progressive dysphagia mainly to solids. She gave a 3-month history of increasing heartburn, vomiting, tiredness, lethargy, anorexia and 13 kg weight loss. Her past medical history was unremarkable and she was a non-smoker. Physical examination revealed evidence of significant weight loss and dehydration only. Gastroscopy revealed mild oesophagitis, tongues of Barrett oesophagus and mild antral gastritis. CT scan of the thorax and abdomen was normal. Unfortunately her condition deteriorated rapidly and she died from aspiration pneumonia. Postmortem examination revealed thickening of the muscular wall of lower oesophagus and pylorus, but without any malignancy. The histological assessment of the oesophageal as well as gastric biopsies confirmed the diagnosis of gastrointestinal amyloidosis accounting for her symptoms of dysphagia and vomiting respectively.
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Affiliation(s)
| | - Dina Mansour
- Conquest Hospital, Medicine, The Ridge, St Leonards On Sea, Kent, TN37 7RD, UK
| | - Stuart Barnes
- Conquest Hospital, Histopathology, The Ridge, St Leonards On Sea, TN37 7RD, UK
| | - Mark W Whitehead
- Conquest Hospital, Gastroenterology, The Ridge, St Leonards On Sea, Kent, TN37 7RD, UK
| | - Stuart A Bruce
- Conquest Hospital, The Ridge, St Leonards On Sea, Kent, TN37 7RD, UK
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Lazaraki G, Nakos A, Katodritou E, Pilpilidis I, Tarpagos A, Katsos I. A rare case of multiple myeloma initially presenting with pseudoachalasia. Dis Esophagus 2008; 22:E21-4. [PMID: 19207546 DOI: 10.1111/j.1442-2050.2008.00903.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pseudoachalasia is a rare clinical entity with clinical, radiographic, and manometric features often indistinguishable from achalasia. Primary adenocarcinomas arising at the gastroesophageal junction or a tumor of the distal esophagus are the most frequent causes of pseudoachalasia. Rarely, processes other than esophagogastric cancers including chronic idiopathic intestinal pseudo-obstruction, amyloidosis, sarcoidosis, Chagas' disease, vagotomy, antireflux surgery, pancreatic pseudocysts, von Recklinghausen's neuroinomatosis, gastrointestinal stromal tumor, and other malignancies and rare genetic syndromes, may lead to the development of pseudoachalasia. Secondary achalasia is extremely rare, with less than 100 cases reported in the literature so far. Gastrointestinal manifestations in primary or secondary amyloidosis include abdominal pain, diarrhea, constipation, malabsorption, obstruction, motility disturbance, intestinal infarction, perforation, and hemorrhage; however, gastrointestinal tract involvement is asymptomatic in most instances. We present here a rare case of multiple myeloma initially presenting with dysphagia because of esophageal amyloidosis and manometric findings typical of achalasia.
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Affiliation(s)
- Georgia Lazaraki
- Department of Gastrointestinal Oncology, Theagenion Cancer Hospital, 54248 Thessaloniki, Greece.
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20
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Abstract
Amyloidosis is characterized by extracellular deposition of abnormal protein. There are six types: primary, secondary, hemodialysis-related, hereditary, senile, and localized. Primary (AL) amyloidosis is associated with monoclonal light chains in serum and/or urine with 15% of patients having multiple myeloma. Secondary (AA) amyloidosis is associated with inflammatory, infectious, and neoplastic diseases. The presentation is protean, including macroglossia, a dilated and atonic esophagus, gastric polyps or enlarged folds, and luminal narrowing or ulceration of the colon. Amyloid deposition in the gastrointestinal (GI) tract is greatest in the small intestine. The symptoms include diarrhea, steatorrhea, or constipation. Pseudo-obstruction carries a particularly grave prognosis, often not responding to pro-motility agents. Hepatic involvement is common, but the clinical manifestations are usually mild with hepatomegaly and an elevated alkaline phosphatase level. Biopsies to diagnose amyloidosis can be taken from the fat, kidney, intestine, or bone marrow. The safety of liver biopsies is controversial. With Congo Red stain, amyloid appears red in normal light and apple-green in polarized light. Treatment for AL amyloidosis is chemotherapy and stem cell transplantation; treatment for AA amyloidosis is control of the underlying disease. Amyloidosis should be considered in patients with proteinuria, cardiomyopathy, hepatomegaly (with mildly abnormal liver tests), peripheral and autonomic neuropathy, weight loss, and GI symptoms.
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Affiliation(s)
- Ellen C Ebert
- Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey 09803, USA
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James DG, Zuckerman GR, Sayuk GS, Wang HL, Prakash C. Clinical recognition of Al type amyloidosis of the luminal gastrointestinal tract. Clin Gastroenterol Hepatol 2007; 5:582-8. [PMID: 17428737 DOI: 10.1016/j.cgh.2007.02.038] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Amyloidosis is characterized by the pathologic deposition of specific proteins throughout the body. Gastrointestinal involvement with amyloid associated with plasma cell dyscrasias (AL type amyloidosis) is common, but systematic description of the condition is lacking. The aim of this investigation was to characterize the clinical presentation, endoscopic findings, and histopathologic correlates in a series of patients with systemic AL amyloidosis of the luminal gastrointestinal tract. METHODS Eligible patients were identified by interrogating the histopathology database of our institution during a 14-year time period. Medical record, histopathologic, and laboratory data were collected, analyzed, and correlated with endoscopic findings. RESULTS Nineteen patients with systemic AL amyloidosis of the luminal gastrointestinal tract were identified. Gastrointestinal symptoms or signs related to amyloid involvement were noted in 95% of patients; abdominal pain, change in bowel habits, overt gastrointestinal bleeding, and complaints related to altered motility were the predominant presentations. Endoscopic abnormalities were found in nearly three fourths of patients, including ulcerations and submucosal hematomas. When gastrointestinal bleeding was the presenting symptom, submucosal hematomas were a common finding during endoscopic evaluation. CONCLUSIONS AL type amyloidosis of the luminal gastrointestinal tract is a rare disease that presents with common, nonspecific complaints. The endoscopic detection of a submucosal hematoma in the setting of gastrointestinal bleeding in patients with plasma cell dyscrasias should raise suspicion for the disease.
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Affiliation(s)
- Dustin G James
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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22
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Gockel I, Eckardt VF, Schmitt T, Junginger T. Pseudoachalasia: a case series and analysis of the literature. Scand J Gastroenterol 2005; 40:378-85. [PMID: 16028431 DOI: 10.1080/00365520510012118] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Pseudoachalasia frequently cannot be distinguished from idiopathic achalasia by manometry, radiologic examination or endoscopy. Mechanisms proposed to explain the clinical features of pseudoachalasia include a circumferential mechanical obstruction of the distal esophagus or a malignant infiltration of inhibitory neurons within the myenteric plexus. MATERIAL AND METHODS Between January 1980 and December 2002, the clinical features of 5 patients with pseudoachalasia and 174 patients with primary achalasia, diagnosed in a single center, were compared. A literature analysis of the etiology of pseudoachalasia for the time period 1968 to December 2002 was performed. The search concentrated on the databases and online catalogues PubMed, Web of Science, Cochrane Library and Current Contents Connect. RESULTS In our case series, patients with pseudoachalasia reported a shorter duration of symptoms and tended to be older than patients with primary achalasia. Conventional manometry, endoscopy and radiologic examination of the esophagus proved to be of little value in distinguishing between the diseases. In the majority of cases only surgical exploration revealed the underlying cause. A coincidence of primary achalasia and disorders of the gastroesophageal junction was excluded by showing return of peristalsis following treatment. The analysis of the literature showed a total of 264 cases of pseudoachalasia in 122 publications. Most cases of were due to malignant disease (53.9% primary and 14.9% secondary malignancy), followed by benign lesions (12.6%) and sequelae of surgical procedures at the distal esophagus or proximal stomach (11.9%). In rare instances, the disease was an expression of a paraneoplastic process due to distant neuronal involvement rather than to local invasion with destruction of the myenteric plexus (2.6%). CONCLUSIONS The diagnosis of pseudoachalasia is difficult to establish by conventional diagnostic measures. The main distinguishing feature of secondary versus primary achalasia is the complete reversal of pathologic motor phenomena following successful therapy of the underlying disorder.
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Affiliation(s)
- Ines Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg-University Mainz, Germany.
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23
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Poullos PD, Stollman N. Gastrointestinal Amyloidosis: Approach to Treatment. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2003; 6:17-25. [PMID: 12521568 DOI: 10.1007/s11938-003-0029-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The main treatment goals in amyloidosis are twofold: 1) to diagnose the underlying disease state accurately to guide effective primary therapy (if available) and 2) to ameliorate symptoms. The correct diagnosis is essential because disease-modifying therapies vary widely according to the underlying primary pathology. Primary treatment options remain limited. The best evidence is for high-dose chemotherapy, followed by autologous stem cell transplantation in patients with primary systemic amyloidosis. High-flux hemodialysis (HD) may prevent HD-related amyloidosis. Liver transplantation may be an option for patients with familial amyloidotic polyneuropathy. Several novel specific therapies are under investigation, including small molecule drugs and vaccines. Their efficacy and safety in humans remain to be demonstrated. In the absence of specific cures, symptom-directed therapy assumes a paramount role and can improve quality of life by mitigating diarrhea or pain, for example.
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Affiliation(s)
- Peter D. Poullos
- San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, GI Suite 3-D, San Francisco, CA 94110, USA
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24
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Ng SB, Busmanis IA. Rare presentation of intestinal amyloidosis with acute intestinal pseudo-obstruction and perforation. J Clin Pathol 2002; 55:876. [PMID: 12401832 PMCID: PMC1769795 DOI: 10.1136/jcp.55.11.876] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- S B Ng
- Department of Pathology, Singapore General Hospital, Outram Road, 169608 Singapore;
| | - I A Busmanis
- Department of Pathology, Singapore General Hospital, Outram Road, 169608 Singapore;
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25
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López-Cepero Andrada JM, Jiménez Arjona J, Amaya Vidal A, Rubio Garrido J, Navas Relinque C, Soria de la Cruz MJ, Benítez Roldán A. [Pseudoachalasia and secondary amyloidosis in a patient with rheumatoid arthritis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:398-400. [PMID: 12069703 DOI: 10.1016/s0210-5705(02)70274-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rheumatic diseases cover a wide spectrum of clinical syndromes and frequently present with gastrointestinal alterations. Systemic amyloidosis is associated with infectious diseases or chronic inflammatory processes such as rheumatoid arthritis and it can also affect the gastrointestinal tract. Although esophageal involvement is difficult to quantify because its course is frequently asymptomatic, systemic amyloidosis is recognized as a cause of motor disorders of the esophagus. Typical manometric patterns, including achalasia, are usually absent. Esophageal involvement due to amyloid deposits usually corresponds to primary amyloidosis as only a few cases of secondary esophageal deposits (type AA) have been described. We describe a new case of this exceptional association that first presented as dysphagia in a patient with rheumatoid arthritis. The initial suspicion of pseudoachalasia led to the definitive diagnosis of secondary amyloidosis.
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Hurlstone DP. Iron-deficiency anemia complicating AL amyloidosis with recurrent small bowel pseudo-obstruction and hindgut sparing. J Gastroenterol Hepatol 2002; 17:623-4. [PMID: 12084040 DOI: 10.1046/j.1440-1746.2002.02719.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
AL amyloidosis complicating multiple myeloma is rare but well recognized. Endoscopic appearances of amyloid in the gastrointestinal tract can, however, be highly variable. Macroscopic appearances of the duodenum can range from scalloping (often seen in celiac disease) to that of duodenitis; erosive disease, frank ulceration and even protruberant masses. The importance of small bowel biopsies at the time of duodenal intubation and in gastroscopic examinations for iron deficiency anemia, must therefore be stressed.
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Affiliation(s)
- D P Hurlstone
- Gastroenterology and Liver Unit at the Royal Hallamshire Hospital, Sheffield, England.
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27
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Abstract
PURPOSE Although malabsorption syndrome is encountered frequently by general internists and gastroenterologists and is common to various underlying disease processes, primary amyloidosis is often overlooked during medical evaluation. We describe the diagnosis, natural history, and laboratory features of a subgroup of patients with primary amyloidosis who presented predominantly with gastrointestinal symptoms and with evidence of a malabsorption syndrome. SUBJECTS AND METHODS We reviewed all patients diagnosed with amyloidosis and malabsorption syndrome who had been seen at the Mayo Clinic from 1960 through 1998. Nineteen patients with small bowel biopsy results showing primary amyloid and with laboratory evidence of a malabsorption syndrome were studied. RESULTS The most common symptoms were diarrhea or steatorrhea in 95% of patients (n = 18), anorexia in 42% (n = 8), and dizziness in 32% (n = 6). The most common signs included weight loss in all 19 patients, with a median weight loss of 30 pounds (range, 2 to 134 pounds) and hypotension or orthostatic changes in 10 patients (53%). The median time from symptom onset to diagnosis was 7 months. Most patients had evidence of amyloid involvement of other organs. Only 3 patients (16%) were diagnosed correctly upon initial presentation. Serum or urine protein electrophoresis results were positive in 95% of patients (n = 18). Median survival was 11 months from histologic diagnosis. CONCLUSIONS Primary systemic amyloidosis should be considered in the differential diagnosis of malabsorption syndrome. All patients over 30 years of age with a malabsorption syndrome should have screening serum and urine immunofixation before undergoing a small bowel biopsy.
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Affiliation(s)
- S R Hayman
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Kumar S, Dispenzieri A, Lacy MQ, Litzow MR, Gertz MA. High incidence of gastrointestinal tract bleeding after autologous stem cell transplant for primary systemic amyloidosis. Bone Marrow Transplant 2001; 28:381-5. [PMID: 11571511 DOI: 10.1038/sj.bmt.1703155] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2001] [Accepted: 06/11/2001] [Indexed: 11/09/2022]
Abstract
Peripheral blood stem cell transplants have been associated with better response rates than conventional chemotherapy in patients with primary systemic amyloidosis. A higher incidence of gastrointestinal (GI) tract bleeding has been observed among amyloidosis patients undergoing peripheral stem cell transplantation. We retrospectively reviewed the medical records of such patients to identify those who had GI tract bleeding in the post-transplant period. Forty-five patients were studied. Nine patients had GI tract bleeding in the post-transplant period. The median post-transplant duration to onset of bleeding was 9.5 days (range 1 to 48 days). Three patients had lower GI tract bleeding, two had upper GI tract bleeding, and four had both. Diffuse esophagitis and gastritis were the most common findings on endoscopy. There were no correlations among the age, platelet nadir, or CD34 count of the graft and the risk of bleeding. Women were more likely to have GI tract bleeding (P = 0.015), as were patients with slow platelet engraftment (P = 0.02). Patients with multiorgan involvement and those on hemodialysis appeared to be at a higher risk of GI tract bleeding. The mean post-transplant hospital stay for those with GI tract bleeding was 37 days compared with 14.5 days for those who did not have GI tract bleeding (P = 0.0047).
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Affiliation(s)
- S Kumar
- Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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29
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 30-1999. An 86-year-old man with gastrointestinal bleeding and small-bowel obstruction. N Engl J Med 1999; 341:1063-71. [PMID: 10502597 DOI: 10.1056/nejm199909303411408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
MESH Headings
- Aged
- Aged, 80 and over
- Diagnosis, Differential
- Gastrointestinal Hemorrhage/etiology
- Humans
- Ileal Neoplasms/complications
- Ileal Neoplasms/pathology
- Ileum/pathology
- Intestinal Obstruction/etiology
- Intestine, Small/diagnostic imaging
- Intestines/blood supply
- Ischemia/diagnosis
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/complications
- Lymphoma, Large B-Cell, Diffuse/pathology
- Male
- Tomography, X-Ray Computed
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30
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Abstract
Systemic amyloidosis is caused by a variety of different diseases and frequently involves the gastrointestinal tract. Each type of amyloid affects the gastrointestinal tract differently. This article reviews the unique pathogenesis, pattern of gastrointestinal disposition, diagnosis, and treatment of the five systemic amyloidoses, and discusses the gastrointestinal diseases that cause systemic amyloidosis: inflammatory bowel disease and familial Mediterranean fever.
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Affiliation(s)
- S Friedman
- Division of Gastroenterology, Mount Sinai Medical Center, New York, New York, USA
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31
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Okuda Y, Takasugi K, Oyama T, Oyama H, Nanba S, Miyamoto T. Intractable diarrhoea associated with secondary amyloidosis in rheumatoid arthritis. Ann Rheum Dis 1997; 56:535-41. [PMID: 9370878 PMCID: PMC1752446 DOI: 10.1136/ard.56.9.535] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To examine the clinical characteristics of intractable diarrhoea associated with secondary amyloidosis in rheumatoid arthritis (RA). METHODS Of 179 RA patients with biopsy confirmed secondary amyloidosis, 24 cases (23 women and one man) with intractable diarrhoea lasting for more than one month were retrospectively evaluated. RESULTS The mean (SD) duration of diarrhoea was 87 (64) days. Prodromal symptoms of gastrointestinal dysfunction (n = 21) and impaired peristalsis (n = 16) were observed. Laboratory data showed hypoproteinaemia (4.7 (0.85) g/dl) caused by malabsorption or protein loss and high values of C reactive protein (17.0 (9.3) mg/dl). Recurrence of intractable diarrhoea (n = 4) and transition from intractable diarrhoea to other gastrointestinal problems of amyloidosis (ischaemic colitis (n = 2) and intestinal pseudo-obstruction (n = 4)) were observed. In 19 patients (25 episodes) the duration of intravenous hyperalimentation at remission (18 episodes) was 68 (52) days. Corticosteroid pulse therapy was administered to 10 patients (11 times) and the time elapsed from the end of corticosteroid pulse therapy to the end of diarrhoea was 18 (14) days. One and five year survival rates after the onset of intractable diarrhoea were 73.4% and 38.9%. Seven of 13 patients (54%) had died as a result of infectious diseases. CONCLUSION Intractable diarrhoea associated with secondary amyloidosis in RA is a serious clinical entity and the prognosis is poor. Although it is assumed that intravenous hyperalimentation treatment and corticosteroid pulse therapy are favourable regimens for intractable diarrhoea, the patients should be monitored for possible infectious complications.
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Affiliation(s)
- Y Okuda
- Department of Internal Medicine, Dohgo Spa Hospital, Ehime, Japan
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32
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Buchholz DW. Esophageal dysfunction due to neurological disorders. Dysphagia 1996; 11:30-3. [PMID: 8556876 DOI: 10.1007/bf00385797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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33
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Affiliation(s)
- E Pascali
- Institute of General Clinical Medicine, University of Trieste, Cattinara Hospital, Italy
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34
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Menke DM, Kyle RA, Fleming CR, Wolfe JT, Kurtin PJ, Oldenburg WA. Symptomatic gastric amyloidosis in patients with primary systemic amyloidosis. Mayo Clin Proc 1993; 68:763-7. [PMID: 8331978 DOI: 10.1016/s0025-6196(12)60634-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We reviewed the clinical records of 769 patients with primary systemic amyloidosis who had been examined at Mayo Clinic Jacksonville (Jacksonville, Florida) or Mayo Clinic Rochester (Rochester, Minnesota) during a 12-year period (1978 through 1989). Of these 769 patients, 59 (8%) had biopsy-established gastrointestinal amyloidosis, and 8 (1%) had symptomatic gastric amyloidosis. All eight patients with symptomatic gastric amyloidosis had hematemesis or prolonged nausea and vomiting in association with weight loss. Additional findings were gastroparesis (in three patients), gastric tumor (in one), and gastric outlet obstruction (in one). Macroglossia was present in two patients, and multiple myeloma was diagnosed in three. Six of the eight patients had coexisting small bowel amyloidosis and weight losses of 6.5 to 22.5 kg. Congo red staining identified gastric amyloid in the media of blood vessels in all cases. All cases stained selectively for lambda (seven cases) or kappa (one) light chain. All eight patients died; the median duration of survival after diagnosis was 13.8 months (range, 0.5 to 39.5). Death was due to cardiac failure (three patients), renal failure (two), chronic gastrointestinal obstruction and severe cachexia (two), or hepatic failure (one). Chemotherapy was given to seven patients but was only partially effective for ameliorating symptoms in one.
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Affiliation(s)
- D M Menke
- Department of Pathology, Mayo Clinic Jacksonville, Florida 32224
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35
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Ishikawa Y, Ishii T, Masuda S, Asuwa N, Kiguchi H. Multiple penetrating colonic ulcers in secondary amyloidosis caused by rheumatoid arthritis. ACTA PATHOLOGICA JAPONICA 1993; 43:59-64. [PMID: 8465657 DOI: 10.1111/j.1440-1827.1993.tb02915.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
An autopsy case of multiple penetrated colonic ulcers with secondary amyloidosis caused by rheumatoid arthritis in a 61 year old woman is reported. Amyloid deposition was conspicuous in the transverse colon with numerous penetrating ulcers that were circumferentially scattered. Deposition was mainly in the small vessel walls of the submucosal layers. In the quantitative comparison of the histological components between the colonic segments affected by severe and mild ulcer formation, occlusive vascular amyloid deposition was revealed more frequently in the severe involved portion than in the mild involved portion. In addition, submucosal fibrosis that tended to appear around ulcers was more extensive and thicker in the former than in the latter. The complete vascular occlusion caused by amyloid deposition was particularly concentrated in the submucosal layer adjacent to the ulcer. These findings indicate that peripheral circulatory disturbance by amyloid deposition in the small vascular walls leads to ulcer formation in the colon.
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Affiliation(s)
- Y Ishikawa
- Department of Pathology, Hachioji Medical Center, Tokyo Medical College, Japan
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36
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Bjerle P, Ek B, Linderholm H, Steen L. Oesophageal dysfunction in familial amyloidosis with polyneuropathy. CLINICAL PHYSIOLOGY (OXFORD, ENGLAND) 1993; 13:57-69. [PMID: 8435977 DOI: 10.1111/j.1475-097x.1993.tb00317.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Sixteen patients with familial amyloidosis and polyneuropathy (FAP) and 14 health subjects underwent oesophageal manometry. Six of the patients had a severe oesophageal dysmotility with almost completely abolished propulsive pressure waves on swallowing in the lower 2/3 of the oesophagus. Ten patients had moderate dysfunction with reduced propulsive pressure wave amplitudes. Neostigmine increased the pressure wave amplitudes in healthy subjects but less so in the FAP patients. Scopolamine (Scopyl)-terbutaline (Bricanyl) almost abolished the propulsive pressure waves in healthy subjects and all patients in the lower 2/3 of the esophagus. Oesophageal distensibility, tested by inflating a rubber balloon in the oesophagus, was similar in FAP patients and healthy subjects. Thus, it is unlikely that amyloid deposits in the mucosal wall increased the oesophageal stiffness. An autonomic, predominantly vagal, denervation probably explains the disturbed function.
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Affiliation(s)
- P Bjerle
- Department of Clinical Physiology, University of Umeå, Sweden
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37
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Abstract
Spontaneous duodenal perforation in two patients with primary systemic amyloidosis associated with multiple myeloma is described. Bowel perforation is a rare and often fatal complication of amyloidosis, and duodenal perforation has not been previously described. Both patients survived the bowel perforation with conservative management. Bowel perforation should be suspected in patients with amyloidosis presenting with acute abdominal pain, and active non-surgical management can be associated with prolonged survival.
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Affiliation(s)
- A G Fraser
- Department of Medicine, Royal Free Hospital School of Medicine, London
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38
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Suhr O, Danielsson A, Steen L. Bile acid malabsorption caused by gastrointestinal motility dysfunction? An investigation of gastrointestinal disturbances in familial amyloidosis with polyneuropathy. Scand J Gastroenterol 1992; 27:201-7. [PMID: 1502482 DOI: 10.3109/00365529208999949] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastrointestinal dysfunction due to autonomous neuropathy is a complication described in various diseases such as diabetes mellitus, multiple sclerosis, and familial amyloidosis with polyneuropathy. We present the results of a prospective investigation of bile acid malabsorption in 17 patients with familial amyloidosis by means of 75Se-labelled homocholic-tauro acid (SeHCAT). The diagnosis was in all cases verified by the DNA test for mutation of transthyretin in position 30. Small-intestinal biopsy specimens were examined for deposits of amyloid, and the presence of gastric retention was evaluated by gastroscopy. In addition, the patients were investigated for bacterial overgrowth by means of the bile acid breath test (BABT). A high frequency of abnormal BABT results (44%) was encountered. However, 65% also had abnormal low SeHCAT values, indicating bile acid malabsorption. Only two patients had abnormal BABT and normal SeHCAT results, indicating bacterial contamination of the small intestine. Bile acid losses increased with the duration of gastrointestinal symptoms. Significantly lower SeHCAT values were encountered in patients with gastric retention, whereas the occurrence of amyloid deposits in small-intestinal biopsy specimens was without effect on SeHCAT retention. Bile acid malabsorption is frequently encountered in familial amyloidosis with polyneuropathy and seems to be more closely associated with gastrointestinal motility dysfunction than with amyloid deposits in the intestinal mucosa.
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Affiliation(s)
- O Suhr
- Dept. of Medicine, University Hospital, Umeå, Sweden
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39
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Matsumoto T, Iida M, Hirakawa M, Hirakawa K, Kuroki F, Lee S, Nanbu T, Fujishima M. Breath hydrogen test using water-diluted lactulose in patients with gastrointestinal amyloidosis. Dig Dis Sci 1991; 36:1756-60. [PMID: 1748046 DOI: 10.1007/bf01296621] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To investigate small bowel motility in gastrointestinal amyloidosis, lactulose breath hydrogen tests were performed on 16 patients with histologically proven amyloidosis and 12 age- and sex-matched controls. Fasting breath hydrogen concentration (FBHC) was not significantly different between the two groups, but there was a tendency for FBHC in symptomatic amyloidosis patients (median 31.5, range 3-78 ppm) to be higher than in asymptomatic amyloidosis patients (4, 0-34 ppm, 0.05 less than P less than 0.1) and controls (6, 1-19 ppm, 0.05 less than P less than 0.1). Orocecal transit time (OCTT) was significantly delayed in the amyloidosis group (median 150, range 40-220 min) when compared to the controls (60, 20-110 min, P less than 0.01), but OCTT was not statistically different between symptomatic and asymptomatic amyloidosis patients. These data suggest an impaired motility of the stomach and small intestine in gastrointestinal amyloidosis and the possible role of small intestinal dysfunction such as bacterial overgrowth and malabsorption in the occurrence of symptoms in this disorder.
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Affiliation(s)
- T Matsumoto
- Second Department of Internal Medicine, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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40
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Trinh TD, Jones B, Fishman EK. Amyloidosis of the colon presenting as ischemic colitis: a case report and review of the literature. GASTROINTESTINAL RADIOLOGY 1991; 16:133-6. [PMID: 2016025 DOI: 10.1007/bf01887327] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Review of the English literature revealed 21 cases describing abnormalities on barium enema secondary to amyloidosis of the colon. These cases were categorized as to frequency of specific barium enema findings and distribution within the colon. The most common radiologic findings were luminal narrowing (11 of 21), loss of haustrations (10 of 21), thickened mucosal folds (8 of 21), mucosal nodularity (8 of 21), and ulceration (6 of 21). The most frequent locations of disease within the colon were the descending and rectosigmoid portions (13 of 21). We present a case of primary amyloidosis that demonstrates the findings of bowel wall thickening and luminal narrowing on double-contrast barium enema and computed tomography (CT). Pathologic examination in our case, in addition to similar observations from the literature, suggests that at least a part of the radiologic changes of colonic amyloid can be attributed to bowel ischemia.
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Affiliation(s)
- T D Trinh
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Fraser AG, Arthur JF, Hamilton I. Intestinal pseudoobstruction secondary to amyloidosis responsive to cisapride. Dig Dis Sci 1991; 36:532-5. [PMID: 2007373 DOI: 10.1007/bf01298889] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A case of chronic intestinal pseudoobstruction secondary to systemic amyloidosis in a patient with multiple myeloma is described. Gastrointestinal symptoms and indices of nutrition improved markedly after commencing treatment with cisapride, which may have been responsible for relatively prolonged survival compared with similar reported cases.
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Affiliation(s)
- A G Fraser
- Gastroenterology Unit, Auckland Hospital, New Zealand
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Abstract
Colonic pseudo-obstruction may have many possible causes. Some of these are well described and pose no diagnostic problems. Drug-related colonic pseudo-obstruction remains underreported, but is of importance in modern society where drugs are endemically abused. This case highlights the importance of drugs in altering colonic motility and emphasizes the nonsurgical management of this condition.
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Affiliation(s)
- S K Ohri
- Department of Surgery, Royal Postgraduate Medical School, Hammersmith Hospital, London, United Kingdom
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Abstract
Gastrointestinal motility is the function of gastrointestinal smooth muscle. It is controlled by both the intrinsic and extrinsic nerves of the gastrointestinal tract and, to a lesser degree, the gastrointestinal hormones. Therefore, any abnormality of the above factors, theoretically, can cause gastrointestinal dysmotility. In a clinical situation, commonly seen is gastrointestinal dysmotility caused by either smooth muscle or intrinsic and extrinsic nerves dysfunction. Diseases that cause smooth muscle dysfunction include familial visceral myopathies, nonfamilial visceral myopathies, collagen disease, muscular dystrophies, amyloidosis, thyroid disease, and so on. Diseases that cause enteric nerve dysfunction include familial visceral neuropathies, nonfamilial visceral neuropathies, diabetes mellitus, Chagas' disease, ganglioneuromatosis of the intestine, visceral neuropathy of carcinomatosis, Parkinson's disease, and so on. The patients with neuromuscular disease of the gastrointestinal tract have a wide range of clinical manifestations regardless of the underlying cause. At one end of the spectrum, the patients may be asymptomatic, and at the other end of the spectrum, the patients may have functional obstruction of the gastrointestinal tract. Plain abdominal x-rays, upper gastrointestinal (UGI) and small bowel x-rays, enteroclysis, barium enema, and manometric studies are useful for the work-up of these patients. Enteroclysis is especially helpful in ruling out mechanical obstruction of the small intestine in patients with chronic intestinal pseudo-obstruction. Treatment is mainly symptomatic and supportive. There is no effective drug to improve gastrointestinal motility. Surgery may be helpful in selected cases of severe gastrointestinal dysmotility.
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Abstract
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.
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Affiliation(s)
- M Camilleri
- Gastroenterology Research Unit, Mayo Clinic, Rochester, MN 55905
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Affiliation(s)
- R A Kyle
- Mayo Medical School, Rochester, Minnesota
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Kim CH, Kim S, Kwon OJ, Han SK, Lee JS, Kim KY. Pulmonary diffuse alveolar septal amyloidosis--diagnosed by transbronchial lung biopsy. Korean J Intern Med 1990; 5:63-8. [PMID: 2271513 PMCID: PMC4534991 DOI: 10.3904/kjim.1990.5.1.63] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Diffuse alveolar septal involvement is a rare form of pulmonary amyloidosis. Antemortem diagnosis is unusual, and most of the reported cases were diagnosed at autopsy. It has recently been reported that transbronchial lung biopsy via a flexible fiberoptic bronchoscope was a relatively safe method to confirm diffuse alveolar septal amyloidosis. We report a case of pulmonary diffuse alveolar septal amyloidosis confirmed by transbronchial lung biopsy. The patient's chief complaints were dyspnea on exertion and epigastric pain aggravated over a one-year period, while a chest roentgenogram showed bilateral diffuse interstitial infiltration. This case also showed nephrotic syndrome, cardiac arrhythmia, congestive heart failure, a tingling sensation in both hands and multiple nodules in the gastrointestinal tracts, suggesting involvement of the kidney, heart, peripheral nerves and gastrointestinal tracts. We propose that when diffuse interstitial lung disease is present with systemic signs such as nephrotic syndrome or cardiac arrhythmia, amyloidosis should be considered as a possible diagnosis. Also, transbronchial lung biopsy may be a useful confirmative diagnostic tool.
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Affiliation(s)
- C H Kim
- Department of Internal Medicine, Seoul National University, College of Medicine, Korea
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Glantz LK, Miller F, Gorevic PD. Idiopathic Amyloidosis Due to AA Protein: A Report of 2 Cases. J Histotechnol 1989. [DOI: 10.1179/his.1989.12.2.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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48
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49
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Diarrhea and weight loss in a 65-year-old man. Am J Med 1989; 86:696-700. [PMID: 2729320 DOI: 10.1016/0002-9343(89)90447-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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50
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González Sánchez JA, Martin Molinero R, Dominguez Sayans J, Jimenez Sanchez F. Colonic perforation by amyloidosis. Report of a case. Dis Colon Rectum 1989; 32:437-40. [PMID: 2714137 DOI: 10.1007/bf02563700] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
One patient with a colonic perforation associated with secondary amyloidosis and ankylosing rheumatoid spondylitis was treated successfully. To our knowledge, this is the first case described of colonic perforation in amyloidosis.
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