Portal de Periódicos da CAPES

Upper Gastrointestinal Bleeding in a Patient With Multiple Myeloma

2011; Elsevier BV; Volume: 142; Issue: 2 Linguagem: Inglês

10.1053/j.gastro.2011.02.069

1528-0012

Sumanth Daram, Elizabeth Paine, Amanda F. Swingley,

Malaria Research and Control

Question: A 53-year-old African American woman was diagnosed with κ-light chain multiple myeloma in 2005. She underwent chemotherapy previously, and stem cell transplantation 4 months before the current hospitalization. She presented with acute upper gastrointestinal (GI) bleeding in the form of hematemesis. The patient underwent emergent esophagogastroduodenoscopy. There was no evidence of active bleeding. A multilobulated, submucosal mass, about 4 × 4 cm, with an overlying ulceration measuring about 10 mm was seen, occupying the proximal corpus along the greater curvature (Figure A) . The ulcer had a nonbleeding visible vessel in its base (Figure B); this vessel was successfully ablated with bipolar cautery. Repeat GI endoscopy was performed 4 days later, which revealed the gastric mass, without evidence of bleeding or stigmata for recurrent bleeding. In addition, a small 1- to 2-mm erosion was seen on the lateral wall of the second portion of duodenum (Figure C). Biopsies were obtained from the duodenal lesion, as well as from the gastric mass. Sections from the gastric and duodenal biopsies showed dense submucosal infiltrates of highly atypical plasmacytic cells with Dutcher bodies and anaplasia. The CD138 immunohistochemical stain reacted positively with these submucosal infiltrates.What diagnosis explains these endoscopic findings?See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.Answer to the Clinical Challenges and Images in GI Question: Image 4: Extramedullary Plasmacytoma Involvement of Multiple MyelomaThe endoscopic findings in this patient with known multiple myeloma are consistent with an extramedullary plasmacytoma. Extramedullary involvement, particularly involvement of the GI tract, in multiple myeloma is rare. Extramedullary involvement accounts for 14% of relapses after autologous stem-cell transplantation, with <5% of those with extramedullary disease having GI involvement, in 1 series.1Alegre A. Granda A. Martínez-Chamorro C. et al.Different patterns of relapse after autologous peripheral blood stem cell transplantation in multiple myeloma: clinical results of 280 cases from the Spanish Registry.Haematologica. 2002; 87: 609-614PubMed Google Scholar The differential diagnosis of upper GI bleeding in myeloma patients is diverse, with the most common etiology being peptic ulcer disease, usually secondary to treatment with anti-inflammatory medications and corticosteroids. Other differential diagnoses include erosive gastritis and duodenitis, amyloid infiltration of the gut wall resulting in increased capillary fragility, and plasmacytoma. Gastric plasmacytomas usually present with nonspecific symptoms such as epigastric pain, nausea, vomiting, and rarely GI bleeding.2Pimmentel R. van Stolk R. Gastric plasmacytoma: a rare cause of massive gastrointestinal bleeding.Am J Gastroenterol. 1993; 88: 1963-1964PubMed Google Scholar Endoscopically, gastric plasmacytomas may present as ulcers or as an ulcerated mass and occasionally as irregularly thickened gastric folds or polyps.3Gutnik S.H. Bacon B.R. Endoscopic appearance of gastric myeloma.Gastrointest Endosc. 1985; 31: 263-265Abstract Full Text PDF PubMed Scopus (8) Google Scholar In this case, there was no recurrence of bleeding after endoscopic therapy. Question: A 53-year-old African American woman was diagnosed with κ-light chain multiple myeloma in 2005. She underwent chemotherapy previously, and stem cell transplantation 4 months before the current hospitalization. She presented with acute upper gastrointestinal (GI) bleeding in the form of hematemesis. The patient underwent emergent esophagogastroduodenoscopy. There was no evidence of active bleeding. A multilobulated, submucosal mass, about 4 × 4 cm, with an overlying ulceration measuring about 10 mm was seen, occupying the proximal corpus along the greater curvature (Figure A) . The ulcer had a nonbleeding visible vessel in its base (Figure B); this vessel was successfully ablated with bipolar cautery. Repeat GI endoscopy was performed 4 days later, which revealed the gastric mass, without evidence of bleeding or stigmata for recurrent bleeding. In addition, a small 1- to 2-mm erosion was seen on the lateral wall of the second portion of duodenum (Figure C). Biopsies were obtained from the duodenal lesion, as well as from the gastric mass. Sections from the gastric and duodenal biopsies showed dense submucosal infiltrates of highly atypical plasmacytic cells with Dutcher bodies and anaplasia. The CD138 immunohistochemical stain reacted positively with these submucosal infiltrates. What diagnosis explains these endoscopic findings? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Answer to the Clinical Challenges and Images in GI Question: Image 4: Extramedullary Plasmacytoma Involvement of Multiple MyelomaThe endoscopic findings in this patient with known multiple myeloma are consistent with an extramedullary plasmacytoma. Extramedullary involvement, particularly involvement of the GI tract, in multiple myeloma is rare. Extramedullary involvement accounts for 14% of relapses after autologous stem-cell transplantation, with <5% of those with extramedullary disease having GI involvement, in 1 series.1Alegre A. Granda A. Martínez-Chamorro C. et al.Different patterns of relapse after autologous peripheral blood stem cell transplantation in multiple myeloma: clinical results of 280 cases from the Spanish Registry.Haematologica. 2002; 87: 609-614PubMed Google Scholar The differential diagnosis of upper GI bleeding in myeloma patients is diverse, with the most common etiology being peptic ulcer disease, usually secondary to treatment with anti-inflammatory medications and corticosteroids. Other differential diagnoses include erosive gastritis and duodenitis, amyloid infiltration of the gut wall resulting in increased capillary fragility, and plasmacytoma. Gastric plasmacytomas usually present with nonspecific symptoms such as epigastric pain, nausea, vomiting, and rarely GI bleeding.2Pimmentel R. van Stolk R. Gastric plasmacytoma: a rare cause of massive gastrointestinal bleeding.Am J Gastroenterol. 1993; 88: 1963-1964PubMed Google Scholar Endoscopically, gastric plasmacytomas may present as ulcers or as an ulcerated mass and occasionally as irregularly thickened gastric folds or polyps.3Gutnik S.H. Bacon B.R. Endoscopic appearance of gastric myeloma.Gastrointest Endosc. 1985; 31: 263-265Abstract Full Text PDF PubMed Scopus (8) Google Scholar In this case, there was no recurrence of bleeding after endoscopic therapy. The endoscopic findings in this patient with known multiple myeloma are consistent with an extramedullary plasmacytoma. Extramedullary involvement, particularly involvement of the GI tract, in multiple myeloma is rare. Extramedullary involvement accounts for 14% of relapses after autologous stem-cell transplantation, with <5% of those with extramedullary disease having GI involvement, in 1 series.1Alegre A. Granda A. Martínez-Chamorro C. et al.Different patterns of relapse after autologous peripheral blood stem cell transplantation in multiple myeloma: clinical results of 280 cases from the Spanish Registry.Haematologica. 2002; 87: 609-614PubMed Google Scholar The differential diagnosis of upper GI bleeding in myeloma patients is diverse, with the most common etiology being peptic ulcer disease, usually secondary to treatment with anti-inflammatory medications and corticosteroids. Other differential diagnoses include erosive gastritis and duodenitis, amyloid infiltration of the gut wall resulting in increased capillary fragility, and plasmacytoma. Gastric plasmacytomas usually present with nonspecific symptoms such as epigastric pain, nausea, vomiting, and rarely GI bleeding.2Pimmentel R. van Stolk R. Gastric plasmacytoma: a rare cause of massive gastrointestinal bleeding.Am J Gastroenterol. 1993; 88: 1963-1964PubMed Google Scholar Endoscopically, gastric plasmacytomas may present as ulcers or as an ulcerated mass and occasionally as irregularly thickened gastric folds or polyps.3Gutnik S.H. Bacon B.R. Endoscopic appearance of gastric myeloma.Gastrointest Endosc. 1985; 31: 263-265Abstract Full Text PDF PubMed Scopus (8) Google Scholar In this case, there was no recurrence of bleeding after endoscopic therapy.