A comparative study of uncomplicated acute non-A-E hepatitis with acute viral hepatitis and acute onset autoimmune hepatitis.

BACKGROUND AND AIMS: Non-A-E hepatitis (NAEH) not leading to acute liver failure (ALF) is poorly documented. The objective was to compare clinical and laboratory features of uncomplicated acute NAEH with acute viral (AVH) and autoimmune hepatitis (AIH) and histopathology in NAEH and AIH. METHODS: Cases of hepatocellular jaundice were included. These were grouped into AVH, AIH and NAEH based on clinical, laboratory and, when indicated, liver biopsy findings. NAEH and AIH were followed up at three months. RESULTS: Of 336 patients with hepatocellular jaundice, 15 (5%) were NAEH, 25 (7%) acute AIH and 45 (14%) AVH. Among NAEH patients, seven (46.7%) were males with a mean age of presentation 39 years. Jaundice (100%) was the most common presentation of NAEH. Peak bilirubin was 10.7 mg/dL. Peak aspartate and alanine aminotransferase (AST, ALT) were 512 and 670 U/L. Five (33.3%) patients had positive anti-nuclear antibody and one had anti-smooth muscle antibody. Mean immunoglobulin G (IgG) levels were 1829. On liver biopsy, all had ballooning degeneration, four (26.7%) had mild and three (20%) moderate interface hepatitis, four (26.7%) mild lymphoplasmacytic infiltrate, one (6.7%) rosette formation, bridging necrosis in none and stage 1 fibrosis in one. Comparing NAEH with AIH, AIH showed significantly older age at presentation, female predisposition, past history of jaundice, lower ALT, more autoantibodies, higher IgG, higher grade interface hepatitis, lymphoplasmacytic infiltrate, rosette formation and higher bilirubin, AST at three months. NAEH and viral hepatitis had similar features. CONCLUSION: Etiology of NAEH is unlikely to be autoimmune and is probably viral, unidentified as yet. Uncomplicated NAEH likely has self-limiting course even without specific treatment.

A Rare Cause of Acute on Chronic Liver Failure (ACLF): Bakuchi-Induced Liver Injury.

Psoralea corylifolia Linn (Bakuchi or Babchi), commonly known as purple fleabane, is a popular herb used in Ayurvedic traditional medicine. Its seeds, called Fructus Psoraleae, are traditionally used for treating leprosy, vitiligo, and psoriasis in the absence of empirical evidence. We report the first case of acute on chronic liver failure (ACLF) caused by Bakuchi, a well-documented hepatotoxic agent, in a middle-aged female. Her liver function deteriorated progressively which prompted us to go for a liver biopsy which was consistent with diagnosis of herb-induced liver injury after excluding all competing causes. Fortunately, the patient improved gradually after herb withdrawal and supportive care. Patients with underlying chronic liver disease (CLD) should be aware of risks in using untested herbal formulations. This case emphasizes the need for increased surveillance to formulate guidelines regarding the regulation and informed use of herbal supplements in patients with chronic liver disease.

A case of giant colonic lipoma removed endoscopically using a modified hybrid technique.

Colonic lipomas are benign adipose tumors and are mostly asymptomatic. They may cause symptoms when their size becomes more than 2 cm. Giant colonic lipoma (GCL) is a rare finding in endoscopy which presents with or without macroscopic ulceration and may lead to iron deficiency anaemia (IDA). The choice of treatment of symptomatic large colonic lipomas has been controversial. Here we are presenting a case of GCL presenting with occult bleeding causing iron deficiency anaemia (IDA). It was removed endoscopically using a combination of noradrenaline, endoloop ligation, and snare cautery technique (modified hybrid technique). Successful removal of the GCL lead to the resolution of IDA. This case report highlights that even GCL can be removed endoscopically, thus surgery can be prevented. Clinical Significance: GCL is an unusual cause of anemia. Modified hybrid endoscopic removal technique improves safety.

Effects of high bilirubin level in pregnancy in Crigler-Najjar syndrome type 2: An extremely rare but important clinical entity to recognize.

Crigler-Najjar is a rare genetic autosomal recessive disorder caused by deficiency of enzyme Uridine 5-Diphosphate Glucuronosyl Transferase (UDP-GT). We report the case of a 24-year-old female with two consecutive pregnancies with a high level of total bilirubin level of 15.1 mg/dl and a direct bilirubin level of 0.8 mg/dl during the first pregnancy. As she was diagnosed case of Crigler Najjar type 2, she was on phenobarbitone 60 mg daily. With careful monitoring, she continued with the same dose. We concluded that even with high bilirubin level (15.1 mg/dl) in pregnancy, no adverse effects to the baby and mother were seen.

Upfront tofacitinib in patients with biological-naïve ulcerative colitis - An Indian multicentric experience.

OBJECTIVES: Tofacitinib is a Janus Kinase inhibitor used for treating moderate to severe ulcerative colitis (UC), mainly after the failure of biological therapy. There is a paucity of data on the outcome of tofacitinib in biological-naïve UC patients. The present study was aimed at analyzing the safety and efficacy of tofacitinib in biological-naïve Indian patients with UC. METHODS: The present study retrospectively evaluated consecutive patients with biological-naïve moderate-to-severe active UC from six tertiary care centers in India receiving tofacitinib from September 2020 to September 2022. Clinical remission or response assessment was based on partial Mayo score (PMS) calculated at baseline and weeks eight, 16 and 24. RESULTS: Total 47 cases (57.4% male, median age: 32 years) were included. After eight weeks of therapy, 33 (70.2%) achieved clinical remission and eight (17.0%) had a primary failure. The baseline serum albumin at treatment initiation was the only independent predictor of remission at eight weeks (Odds ratio: 11.560, 95% CI: 1.478 - 90.404), but not at 16 weeks. By 24 weeks, 59.6% (28/47) of the patients were in remission and 29.8% (14/47) had stopped tofacitinib either due to failure (27.6%) or adverse events (AEs) (2.1%). Among the 47 patients, 10 (21.2%) cases developed AEs during follow-up, including two tuberculosis (4.2%), one cytomegalovirus (CMV) colitis (2.1%) and one herpes zoster (2.1%). Four patients with infection required temporary drug discontinuations. One required permanent discontinuation (mania). CONCLUSION: Upfront tofacitinib is effective in biologic-naïve Indian patients with moderate-severe UC. Further randomized studies are required to validate the study findings.

Determinants of Short-term Mortality in Liver Cirrhosis with Acute Kidney Injury: A Prospective Observational Study.

Background: Acute kidney injury (AKI) occurs in 20-50% of patients with cirrhosis and is associated with a poor prognosis. The aim of the study is to identify the baseline factors affecting mortality in these patients at 30 and 90 days. Methods: We enrolled 117 patients with cirrhosis and AKI and followed them up prospectively. Results: Distribution of International club of ascites AKI stages was: 26 (22.03%) stage 1, 59 (50%) stage 2, and 33 (28%) stage 3. Mortalities at 30 and 90 days were 27 (22.8%) and 33 (27.9%) respectively. On multivariate analysis, variables affecting mortality at 30 days were serum creatinine level>2 mg% at 48 hours after AKI development (adjusted OR 7.93, P=0.02) and leukocytosis (total leucocyte count>11000/mm3 ) at admission (adjusted OR 6.54, P=0.002). Only leukocytosis at admission was a predictor of 90 days mortality (adjusted OR 4.76, P=0.01). Though not statistically significant, patients not responding to standard medical treatment had 3 times higher mortality at 30 days, while the maximum AKI stages (2 and 3) had eight times higher mortality at 90 days. Conclusion: In cirrhosis, AKI increases short-term mortality. High serum creatinine at 48 hours affects mortality at 30 days, while leukocytosis at baseline predicts mortality at 30 and 90 days. Progression to a higher AKI stage impacts prognosis.

Characterization of Circulating Tumor Cells Using Imaging Flow Cytometry in Liver Disease Patients.

Background: Hepatocellular carcinoma (HCC) is asymptomatic at an early stage which delays its timely diagnosis and treatment. Circulating tumor cells (CTCs), derived from a primary or secondary tumor, may help in the management of HCC. Here, we evaluate and characterize CTCs in liver disease patients. Methods: In total, 65 patients, categorized into liver cirrhosis (LC) (n = 30) and HCC (n = 35), were enrolled. Using ImagestreamX MkII imaging flow cytometer, CTCs were detected and characterized using biomarker expression of EpCAM, CK, AFP, CD45, and DRAQ5 in LC and HCC patients. Results: CTCs were detected in 33/35 (94%) HCC patients and in 28/30 (93%) LC patients. In the HCC group, the number of biomarker-positive CTCs was higher in BCLC stage D when compared with others. EpCAM + CK was the most expressed biomarker on CTCs in LC versus HCC (83.3% vs. 77.14%), followed by AFP (80% vs. 65.71%), EpCAM (30% vs. 28.57%), and CK (16.6% vs. 14.28%). The EpCAM cell area was significantly associated (P value = 0.031) with the CTC-positive status. The combination biomarker expression of CTCs cell area (EpCAM, CK, and AFP) performed well with the area under the curve of 0.92, high sensitivity, and specificity in detecting early-stage and AFP-negative HCC as well as in AFP-negative LC cases. Conclusion: Enumeration and cell area of CTCs may be used as a biomarker for early detection of HCC and guiding treatment.

Electrosurgical unit in GI endoscopy: the proper settings for practice.

INTRODUCTION: Electrosurgical unit (ESU) is integral to the endoscopy unit. The proper knowledge of the Mode with setting is essential for good therapeutic outcomes and the safety of the patients. AREAS COVERED: ESU generates high-frequency electric current, which could perform cutting and coagulation for various therapeutic interventions. We review the proper settings for common endoscopic interventions like hemostasis, polypectomy, sphincterotomy, and advanced procedures like endoscopic ultrasound-guided cysto-gastrostomy, bile duct drainage, and endoscopic Ampullectomy. We review the various waveforms of ESU in practice in endoscopy, including special conditions like patients with pacemakers. EXPERT OPINION: Knowledge of the waveforms' duty cycle and crest factor is necessary. A high-duty cycle and lower crest factor lead to a good cutting effect on the tissue. Endocut is the most commonly used Mode in ESU in endoscopic practices like sphincterotomy and polypectomy. Endocut I mode (effect 1-2, duration 3, interval 3) is used for endoscopic sphincterotomy, while Forced Coag mode (Effect 2, 60 W) controls post-sphincterotomy bleeding. Endocut Q mode (Effect 2-3, duration 1, interval 3) is used for cutting the polyp, while Forced Coag mode (Effect 2, 60 W) is used before cutting for pre-coagulation of the stalk.

A Case of Acute Severe Ulcerative Colitis Triggered by COVID-19 Infection.

Ulcerative colitis is a chronic inflammatory bowel condition. One of the theories for its etiopathogenesis is gastrointestinal infections. Although COVID-19 primarily affects the respiratory tract, gastrointestinal involvement is also common. We have reported a case of a 28-year-old male who presented with bloody diarrhea, diagnosed with acute severe ulcerative colitis, triggered by COVID-19 infection after known triggers were excluded.

Efficacy of endoscopic over-the-scope clip fixation for preventing migration of self-expandable metal stents: a systematic review and meta-analysis.

BACKGROUND: Over-the-scope clips (OTSC), both conventional and Stentfix, are believed to anchor the self-expanding metal (SEMS) and prevent migration. We aimed to systematically study the efficacy of endoscopic OTSC fixation of SEMS in prevention of migration. METHODS: We searched electronic databases from inception to November 11, 2022 to identify studies reporting outcomes of OTSC fixation of metal stents. The primary outcome was to calculate the pooled migration rates following OTSC anchorage of SEMS and to compare it with controls (SEMS without any fixation). The secondary outcomes include technical and clinical success of OTSC anchorage of SEMS. Random effect models were used to determine pooled rates of migration and technical as well as clinical success rates of OTSC anchorage of metal stents. RESULTS: A total of 9 studies were included. The pooled rate of migration following OTSC anchorage of SEMS was 0.10 (95%CI, 0.04-0.20, I2 = 43%). The pooled rate of migration following OTSC anchorage of esophageal SEMS was 0.08 (95%CI, 0.04-0.15, I2 = 0%). The pooled risk ratio of SEMS migration following OTSC Stentfix was lower as compared to no fixation of SEMS [RR = 0.24 (95%CI,0.13- 0.43, I2 = 0)]. The pooled technical success rate of OTSC fixation following SEMS was 0.98 (95%CI, 0.81-1.00, I2 = 0%). The pooled clinical success rate of OTSC fixation following SEMS was 0.79 (95%CI, 0.64-0.88, I2 = 56%). All studies had valid and reliable methods to diagnose migration, technical and clinical success. CONCLUSIONS: The use of OTSC clips (conventional or Stentfix) for anchorage had a lower risk of migration of metal stents than no fixation. Future studies should look into prospective multicenter studies on their use to prevent the migration of SEMS.

Placement of a flow diverter-like stent together with coil embolisation for treatment of pancreatic pseudoaneurysm involving the origin of the gastroduodenal artery.

A pancreatic pseudoaneurysm can occur following an attack of pancreatitis. This occurs due to erosion of the pancreatic or peripancreatic artery by the pancreatic enzyme-rich pancreatic secretion pseudocyst. If left untreated, it may cause massive and even fatal haemorrhage. Interventional radiology with coil embolisation of the pseudoaneurysm is the standard of care in such cases. We describe a patient who developed a pseudoaneurysm involving the origin of the gastroduodenal artery (GDA). This was successfully managed by coil embolisation of the pseudoaneurysm along with placement of a flow diverter-like stent in the common hepatic artery across the origin of the GDA leading to exclusion of the diseased segment.

Normal Values of High-resolution Anorectal Manometry of Healthy Indians.

Background/Aims: High-resolution anorectal manometry (HRAM) measures anal sphincter function and anorectal co-ordination. This study aims to provide normal data for HRAM and evaluate the effect of gender, age, and body mass index (BMI) on anorectal functions in healthy Indian subjects. Methods: HRAM was performed on 93 healthy volunteers using a 20-channel, water-perfused catheter. We evaluated anorectal pressures, rectal sensation, and balloon expulsion time. Measurements were recorded during rest, squeeze, and simulated defecation (push). Results: Median anal resting pressure (88 mmHg vs 94 mmHg, P = NS), anal squeeze pressure (165 mmHg vs 147 mmHg, P = NS) were not significantly different between males and females. Rectal pressure (70 mmHg vs 54 mmHg, P = 0.024) and anal pressure (82 mmHg vs 63 mmHg, P = 0.008) during simulated evacuation without rectal distention, were higher in males. The threshold for the first sensation was lower in females (40 mL vs 30 mL, P = 0.021) but desire to defecate (105 mL vs 90 mL, P = NS) and maximum tolerable volume (160 mL vs 140 mL, P = NS) were not significantly different in males and females. Anal residual pressure (median mmHg 83 vs 71 mmHg, P = 0.025) was higher in subjects < 40 years of age. Maximum anal squeeze pressure (185 mmHg vs 165 mmHg, P = 0.024) and maximum rectal pressure (75 mmHg vs 62 mmHg, P = 0.032) during push higher in BMI < 23 kg/m2. Conclusions: The present study provides normal data for the Indian population that can be used for comparison and further work. Age, gender, and BMI affect anorectal parameters in HRAM and should be considered while reporting.

Takayasu Arteritis Presenting as Intestinal Angina: Unusual Presentation of a Rare Disease.

Intestinal angina refers to abdominal pain resulting from reduced mesenteric blood flow. Although atherosclerosis is the most common cause, large vessel vasculitis is emerging as one of the common causes. We have reported a case of an 18-year-old female who presented with classical symptoms of intestinal angina. On evaluation, the patient was found to have an abdominal aortic aneurysm with a compromised mesenteric blood supply. She was started on steroids and methotrexate along with anti-platelets and anticoagulants. She improved following the treatment and didn't have any complaints on follow-up.

Predictors of Severity and Mortality in Chronic Liver Disease Patients With COVID-19 During the Second Wave of the Pandemic in India.

Background Coronavirus disease 2019 (COVID-19) infection in chronic liver disease patients is associated with poor outcomes. In this study, we aimed to evaluate the predictors of severity and mortality in this group of patients during the second wave of the COVID-19 pandemic in India. In addition, we compared cirrhotic patients with COVID-19 with cirrhotic patients from the pre-COVID-19 period. Methodology This was a single-center observational study. We included data from 50 patients with cirrhosis and COVID-19 retrospectively from the discharge/death files. A comparison group of 100 patients with cirrhosis from the pre-COVID period was also analyzed retrospectively. Results The majority of patients had predominantly respiratory symptoms, with fever being the most common symptom (85%). The most common presentation was acute on chronic liver failure (ACLF). The most common form of decompensation was jaundice followed by hepatic encephalopathy. The overall mortality in cirrhotic patients with COVID-19 was double than that in cirrhotic patients from the pre-COVID-19 period. All patients with ACLF succumbed to multiorgan failure. Diabetes was the only comorbidity that was associated with severe infection. Higher creatinine on admission and high D-dimer levels correlated with severity. D-dimer was the only parameter that correlated with severity and mortality on multivariate analysis. None of the comorbidities predicted mortality. Among various composite scores, the Child-Turcotte-Pugh (CTP) score and CURB-65 correlated with mortality. On the area under the receiver operating characteristic analysis, a D-dimer level of >1.1 mg/L was associated with mortality. Conclusions COVID-19 infection in patients with cirrhosis is associated with poor outcomes. D-dimer levels of >1.1 mg/L on admission are a simple parameter to predict mortality. CTP and CURB-65 are composite scores that correlate with mortality in this group of patients.

Pattern of liver function test variations in COVID-19 infection & its clinical significance: A study from a dedicated COVID-19 tertiary care centre from India.

Background & objectives: Coronavirus disease 2019 (COVID-19) affects respiratory, gastrointestinal, cardiovascular and other systems disease. Studies describing liver involvement and liver function test (LFT) abnormalities are sparse from our population. This study was undertaken to estimate the LFT abnormalities in patients with COVID-19 in a tertiary care set up in India. Methods: In this retrospective study conducted at a tertiary care centre in Mumbai, India, all consecutive patients with proven COVID-19 by reverse transcriptase-PCR from March 23 to October 31, 2020 were enrolled. Of the 3280 case records profiled, 1474 cases were included in the study. Clinical characteristics, biochemical parameters and outcomes were recorded. Results: Overall 681 (46%) patient had deranged LFTs. Hepatocellular type of injury was most common (93%). Patients with deranged LFTs had more probability of developing severe disease (P<0.001) and mortality (P<0.001). Advanced age (P<0.001), male gender (P<0.001), diabetes mellitus (P<0.001), lower oxygen saturation levels at admission (P<0.001), higher neutrophil-lymphocyte ratio (P<0.001), history of diabetes mellitus and cirrhosiss were associated with deranged LFTs. Acute liver injury was seen in 65 (4.3%) cases on admission and 57 (3.5%) cases during hospital stay. On multivariate analysis for predicting mortality, age >60 yr serum creatinine >2 mg%, PaO2/FiO2 ratio ≤200 and raised AST >50 IU/l (OR: 2.34, CI: 1.59-3.48, P<0.001) were found to be significant. Interpretation & conclusions: In COVID-19, LFT abnormalities were common, and derangement increased as severity progressed. The presence of deranged LFT worsens the clinical outcome and predicts in-hospital mortality.

Graves' disease associated with cholestatic jaundice and persistent diarrhoea.

Liver involvement in Graves' disease can be seen as a part of autoimmune process or rarely, due to the direct effects of thyrotoxicosis on liver. Hyperthyroidism can also have gastrointestinal manifestations like frequent bowel movements, diarrhoea, even malabsorption with steatorrhoea. We report a 36-year-old man with hyperthyroidism, presenting with cholestatic jaundice and persistent small bowel diarrhoea. He was diagnosed to have Graves' disease and after ruling out more common causes, the cause of cholestatic jaundice was supposed to be Graves' disease. Considering this possibility, the patient was started on treatment with carbimazole. As patient's thyroid function tests started improving, he showed significant clinical and biochemical improvement from liver point of view as well.

"The Innate Tail": An Unusual Cause of Rectal Bleeding in an Adult Male.

Retrorectal cystic hamartomas or tailgut cysts are infrequent congenital lesions presenting as presacral masses originating from the embryonic hindgut. They are commonly diagnosed in middle-aged women. Physicians must have a high index of suspicion to diagnose this rare tumor. We report a case of retrorectal hamartoma in a 70-year-old male presenting as rectal bleeding instead of the usual compressive symptoms. The utility of imaging modalities and the paramount importance of histopathology has been described. The treatment modality is surgical excision to prevent the potential malignant transformation.

Hamartomas císticos retrorretais ou "tailgut cysts" sao lesóes congénitas pouco frequentes que se originam do intestino posterior embrionário e que se apresentam como massas pré-sagradas. São comumente diagnosticados em mulheres de meia-idade. Os médicos devem ter um elevado grau de suspeição para diagnosticar este tumor raro. Relatamos um caso de um hamartoma retrorretal num homem com 70 anos de idade que se apresentou com retorragias e não com os sintomas mais comuns de obstrução. A utilidade dos exames de imagem e a grande importância da histopatologia foi demonstrada neste caso. A modalidade terapêutica adoptada foi a excisão cirúrgica para prevenir uma transformação maligna potencial.

Is the Combination of Rectal Diclofenac and Intravenous Ringer Lactate Superior to Individual Therapy for Prophylaxis of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective, Open-Label, Single-Center Randomized Trial.

METHODS: This was single-center, open-label, randomized trial. Patients who were undergoing ERCP and who were at high risk for the development of PEP were selected for the study. Patients were randomized into 3 treatment groups: diclofenac suppository group, RL group, and a combination group. RESULTS: Eight of 57 patients (14.03%) in the diclofenac group, 9 of 57 patients (15.78%) in the RL group, and 6 of 57 patients (10.52%) in the combination group developed PEP. The incidence of PEP between the three groups was not statistically significant (P = 0.70). Serum amylase level of >252 U/L had 91.3% sensitivity and 92.6% specificity for the diagnosis of PEP. CONCLUSIONS: Post-ERCP pancreatitis is usually mild to moderate 95% times. Female sex, age younger than 50 years, a benign indication of ERCP, and low bilirubin levels have higher chances of PEP. A combination of rectal diclofenac and hydration with RL does not offer better protection for PEP, as compared with individual prophylaxis.

Screening of Family Members of Nonalcoholic Fatty Liver Disease Patients can Detect Undiagnosed Nonalcoholic Fatty Liver Disease Among Them: Is There a Genetic Link?

BACKGROUND & AIMS: Nonalcoholic fatty liver disease (NAFLD) has multifactorial origin. Genetic and environmental factors lead to the biology of this complex disorder. In this study, we screened parents of cases with NAFLD and compared them with parents of cases without NAFLD to see its familial aggregation and the role of patatin-like phospholipase domain containing 3 (PNPLA3). METHOD: It was a cross-sectional study. Parents of probands with NAFLD and without NAFLD were screened with abdominal sonography, anthropometry, blood tests, transient elastography, and PNPLA3 polymorphism. RESULTS: We had enrolled 303 individuals: 51 probands with NAFLD, 50 probands without NAFLD, and their 202 parents. Parents of the NAFLD group had significantly higher metabolic risk factors as compared with parents of the non-NAFLD group. They had a significantly higher rate of fatty liver (P = 0.0001), mean serum aspartate aminotransferase levels (P = 0.011), mean serum alanine aminotransferase levels (P = 0.001),raised fasting and postprandial blood sugar levels, lower mean platelets (P = 0.033) and serum albumin levels (P = 0.005), and higher mean liver stiffness (P = 0.001) on transient elastography.Frequency of PNPLA3 polymorphism within NAFLD group was higher compared to the non-NAFLD group (mutant GG-13.3 vs 3.3%). Similarly, parents of NAFLD group had mutant GG in 15 % versus 5% in parents of non-NAFLD group, (P = 0.105, odds ratio 6), though it was not statistically significant but may be relevant. In this study, offsprings of parents with nonalcoholic steatohepatitis were likely to have GG homozygous allele. A NAFLD16 score based on parent's parameters was calculated to predict the probability of NAFLD occurrence in an overweight obese individual. CONCLUSION: Screening of parents of individuals with NAFLD will help in the identification of undiagnosed NAFLD cases and other metabolic risk factors among them as there is a familial aggregation of NAFLD. One can predict the occurrence of NAFLD in the next generation using the NAFLD16 score.

Non-variceal upper gastrointestinal bleed as first presentation of primary systemic amyloidosis - A case report.

Gastrointestinal (GI) tract manifestations of amyloid deposition include diarrhea, GI hemorrhage, steatorrhea, or constipation. Here, we report an elderly female presenting with GI hemorrhage due to gastric ulceration and 4-6 polypoidal lesions with intermittent ooze in the duodenum as a first presentation of primary systemic amyloidosis. The bleed was managed with proton-pump inhibitors and hemospray application. She received chemotherapy for multiple myeloma after stabilization. A high index of suspicion is needed to diagnose amyloidosis causing GI hemorrhage.