IMAGE | SMALL BOWEL Novel Endoscopic Finding Associated With Gastrointestinal Hemorrhage in a Post-Stem Cell Transplant Patient With Light

A 67-year-old woman with a incidental diagnosis of amyloidosis lambda subtype (AL-amyloid) presented with melena after therapy with heparin for an upper extremity deep vein thrombosis. She had undergone induction treatment with bortezomib, cy-clophosphamide, weekly dexamethasone, and an autologous stem cell transplant 40 days prior to admission. Laboratory results revealed hemoglobin 5.9 g/dL and prothrombin time (PT) 84.8 seconds. An magnetic resonance imaging (MRI) of the abdo-men and pelvis noted circumferential thickening of the duodenum and proximal jejunum. Upper endoscopy revealed multiple circular, shallow, 2–3-mm crater-like defects of the mucosa creating an appearance of a “moon surface mucosa ” throughout the duodenum and jejunum (Figure 1). Duodenal biopsies revealed amyloid deposits involving the lamina propria, submucosa, and blood vessels. Congo red stain for amyloid was positive and showed birefringence under cross-polarized light microscopy (Figure 2). Patients who have undergone an autologous stem cell transplant for primary amyloidosis have a high risk of gastrointestinal bleeding.1 In this patient population, there is a statistically significant prolongation of thrombin time and PT, particularly in patients with hepatic amyloid infiltration and nephrotic syndrome.2 In addition, there may also be a deficiency of the vitamin K-dependent factors and a greater prevalence of acquired factor X deficiency.3 Abnormal light chain proteins are deposited i