Jejunal Wall Thickening and Ulceration in a Patient With Amyloid Light-chain (AL) Amyloidosis
Bibliographic record
Abstract
A 75-year-old man presented to our emergency department with 24 hours of nausea and vomiting 3 days post coronary artery stenting for unstable angina. He had undergone total gastrectomy with esophago-jejunal anastomosis and chemotherapy for gastrointestinal stromal tumour 11 years previously. He also suffered from atrial fibrillation, sicca, carpal tunnel syndrome, calcium pyrophosphate crystal deposition disease (CPPD) arthropathy, and renal nephrolithiasis. His medications included apixaban, aspirin, clopidogrel, iron sulfate, and decreasing doses of prednisone following a CPPD flare. Abdominal CT demonstrated distension and marked wall thickening in the proximal jejunum (Figure 1). A naso-gastric tube returned minimal red blood prompting upper endoscopy (Figure 2A–C) whereupon biopsies of a shallow jejunal ulcer were taken. Pantoprazole was added, and aspirin was discontinued. The patient was discharged 5 days later. Focal jejunal wall thickening and sub-occlusion in a patient with jejunal AL amyloidosis. First- and second-look upper endoscopic findings in jejunal AL amyloidosis. (A) First-look jejunal findings at the esophageal-jejunal anastomosis. (B) Endoscopy was pursued towards a region of proximal jejunal distention. (C) Atypical ulceration was discovered, and biopsies taken. Second-look findings in the same patient 9 days later (D–F) revealed friable mucosa and thickened valvulae conniventes, but no ulceration. Four days after discharge he returned to the emergency department with weakness and melena. His hemoglobin had fallen from 104 to 72 g/L. Repeat upper endoscopy demonstrated friable jejunal mucosa, but healing of the ulcer (Figure 2D–F). Apixaban was discontinued and his hemoglobin stabilized. Echocardiography revealed concentric ventricular hypertrophy typical of amyloidosis. The jejunal ulcer biopsies returned positive for amyloid light-chain (AL) amyloidosis, kappa type. This case demonstrates clinical and endoscopic features of jejunal AL amyloidosis. Amyloid may weaken tissues, which might have caused hemorrhage within the jejunal wall and subsequent sub-occlusion and ulceration (1,2). Amyloidosis should be considered as a potential cause of small bowel ulceration and sub-occlusion in patients with known plasma cell dyscrasias or otherwise unexplained hypertrophic cardiomyopathy. The authors thank Sylvain Durocher, Medical photographer, and the Department of Cardiology, Hôpital Maisonneuve-Rosemont. Conflicts of Interest: None.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".