In the complex world of medical science, the intersection of various diseases often presents unique challenges and learning opportunities. This blog post explores one such intersection - Rheumatoid Arthritis, Gastrointestinal Bleeding, and Amyloidosis. The insights shared in this post are based on the extensive research and clinical experience of Dr. Klaus Mönkemüller.
II. Case Presentation
Our exploration begins with a case study of an elderly female patient with a long history of rheumatoid arthritis. She presented with hematochezia, a condition characterized by the passage of fresh blood through the anus, usually in or with stools. Despite conducting both Esophagogastroduodenoscopy (EGD) and colonoscopy, the cause of the bleeding remained elusive. It was only after a deep enteroscopy that a large segment of edematous and ulcerated mucosa with multiple areas of pink-violaceous discoloration, submucosal hemorrhages, and friability were discovered in the proximal jejunum. Histology revealed submucosal depositions of amyloid, confirming the diagnosis of amyloidosis.
III. Understanding Amyloidosis
Amyloidosis is a condition characterized by the deposition of protein fibrils in the extracellular space of tissues and organ systems. While over 20 different proteins are known to form amyloid fibrils, not all of them cause disease. The proteins that do cause disease, however, can lead to serious health complications.
IV. Types of Amyloidosis
Amyloidosis can be categorized into two main subtypes: amyloid light chain (AL) and amyloid A protein (AA). AL amyloid is a manifestation of a primary plasma cell dyscrasia, which includes conditions like multiple myeloma (MM), smoldering multiple myeloma (SMM), monoclonal gammopathy of undetermined significance (MGUS), and primary amyloidosis. Interestingly, fifteen percent of AL amyloid patients also have multiple myeloma. On the other hand, AA amyloid occurs secondary to systemic inflammation such as rheumatologic disorders, inflammatory bowel disease, and tuberculosis.
V. Manifestations of Amyloidosis
The manifestations of amyloidosis vary greatly depending on the site and extent of the protein deposition. Among the known types of amyloidosis that cause disease, including systemic AA amyloidosis, β2-microglobulin amyloidosis, hereditary systemic amyloidosis, and senile systemic amyloidosis, AL amyloidosis is observed to incur the most gastrointestinal involvement.
VI. Case Analysis
The case of our elderly patient underscores the importance of performing deep enteroscopy in patients with obscure gastrointestinal bleeding. It also highlights the need to consider amyloidosis as a potential etiology of ulcerative small bowel diseases, especially in patients with chronic inflammatory conditions or blood dyscrasias such as multiple myeloma.
In conclusion, the intersection of Rheumatoid Arthritis, Gastrointestinal Bleeding, and Amyloidosis presents a complex clinical picture that requires a comprehensive understanding of these conditions and a meticulous approach to diagnosis and treatment. As medical practitioners, it is crucial to always consider the possibility of amyloidosis, especially in patients presenting with obscure gastrointestinal bleeding and a history of chronic inflammatory conditions or blood dyscrasias. By doing so, we can ensure timely and appropriate treatment, ultimately improving patient outcomes.