© Royal College of Physicians 2020. All rights reserved. 1

Clinical Medicine 2020 Vol 20, No 1: 1–2 IMAGES OF THE MONTH

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Authors: A resident doctor, Second Hospital of Hebei Medical

University, Shijiazhuang, China ; B associate professor, Second

Hospital of Hebei Medical University, Shijiazhuang, China ; C resident

doctor, Second Hospital of Hebei Medical University, Shijiazhuang,

China ; D professor, Second Hospital of Hebei Medical University,

Shijiazhuang, China

Images of the month: Gastrointestinal bleeding with a large liver and a small spleen: a rare appearance of multiple myeloma

Authors: Feng Feng , A Ya Liu , B Xuehui Cao C and Jianhua Liu D

KEYWORDS : Gastrointestinal bleeding , multiple myeloma

Case presentation

A 38-year-old woman presented to the emergency department

because of sudden-onset massive haematemesis. Contrast-

enhanced computed tomography indicated gastrointestinal (GI)

bleeding with an enlarged liver and an unexpectedly-shrunken

spleen (Fig 1 ). Laboratory studies revealed anaemia (haemoglobin

of 5.9 g/dL), proteinuria (urine protein +++), hypercalcaemia

(Ca 2+ of 2.77 mmol/L), and a significantly increased serum β2

microglobulin level (4.1 mg/L, normal range 1.3–2.7 mg/L).

Gastroscopy showed massive blood clots in the stomach and no

clear bleeding site could be found.

We performed an emergency laparotomy and confirmed the

imaging findings. During surgery, the gastrocolic ligament was

transected from the junction between gastroepiploic arteries to the

left side of the cardia. The hepatoduodenal ligament was transected

from the incision of gastric angle to the right side of the cardia.

Based on the abnormal finding of a large liver and a small spleen,

the patient may have had undiscovered systemic diseases, so we

asked a haematologist for consultation. Multiple myeloma was

suspected and subsequently confirmed by bone marrow biopsy

and liver pathological section (Fig 2 ). At the last follow-up, the

Fig 1. Contrast-enhanced computed tomography prior to emergency surgery. a) The arrow indicates delayed

contrast enhancement in the shrunken

spleen. b) The arrow shows a fi ne left

gastric artery arising from the celiac trunk.

c) The arrow indicates a fi ne splenic artery

above the pancreas. d) The arrow shows a

swollen gastric wall and contrast exposure

in the stomach.

CMJv20n1-Liu.indd 1CMJv20n1-Liu.indd 1 11/8/19 3:18 PM11/8/19 3:18 PM

Clinical Medicine Publish Ahead of Print, published on November 8, 2019 as doi:10.7861/clinmed.2019-0326

Copyright 2019 by Royal College of Physicians.

2 © Royal College of Physicians 2020. All rights reserved.

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Feng Feng, Ya Liu, Xuehui Cao and Jianhua Liu

Address for correspondence: Prof Jianhua Liu, Hepatobiliary Department, Second Hospital of Hebei Medical University, 215 Hepingxi Road, Shijiazhuang 050000, China. Email: dr.ljh@outlook.com

patient was in good general condition and receiving her second

chemotherapy course.

Discussion

GI bleeding is extremely rare as the initial manifestation of

multiple myeloma, and in this patient, enlargement of liver and

reduction of spleen also occurred, which made this case extremely

rare. 1 Several possible explanations have been reported with

regard to GI bleeding in multiple myeloma patients. First, the

deposition of amyloid protein in the GI wall leads to increased

capillary fragility. Additionally, myeloma cells may directly infiltrate

the GI tract in the form of plasmacytoma and cause mucosal

hyperplasia, oedema, erosion and repair dysfunction. 2,3

Non-haematologists may not have sufficient understanding of

multiple myeloma and often miss further examination, resulting

in misdiagnosis. For patients suffering GI bleeding combined

with an enlarged liver, an unexpectedly shrunken spleen, and

other abnormalities in laboratory tests such as proteinuria,

Fig 2. Histological results of the patient's bone marrow and liver. a) Bone marrow smear (haematoxylin and eosin stained, ×200) showed obviously

active proliferation of bone marrow nucleated cells with granulocytes predominantly in the middle and late stage and obviously increased plasma cells (the

arrow) with naive plasma cells, binuclear plasma cells and abnormal nuclear plasma cells (naive plasma cell 8.5%; mature plasma cell 42.5%). b) Bone

marrow smear (haematoxylin and eosin stained, ×400) showed a typical binuclear plasma cell (the arrow) with large cell body, a large amount of cytoplasm,

round or oval nucleus, nuclear deviation, and coarse chromatin. c) Bone marrow biopsy showed signifi cantly increased plasma cells (the arrow) and the im-

munohistochemical examination showed positive results in CD138, CD38, Cyclin D1, and κ and negative results in CD56, CD19, CD117, CD20, and λ. d) Liver

pathological section revealed that the liver cells were partially oedematous and partially atrophic with diffused pink-coloured, non-structural substances (the

arrow) in the liver sinuses and the immunohistochemical examination showed positive results in CD138, κ, Ckpan, and Ki-67 (+15%) and negative results in

alpha-fetoprotein, CD10, CD34, CD38, CD68, and λ. Special staining of the liver showed positive results in reticular fi bre staining, periodic acid–Schiff staining,

Masson's trichromatic staining, and weakly positive results in Congo red staining.

hypercalcaemia and high serum β2 microglobulin level, multiple

myeloma should be suspected and bone marrow examination

should be performed to avoid misdiagnoses. ■

References

1 Lin M , Zhu J , Shen H , Huang J . Gastrointestinal bleeding as an

initial symptom in asymptomatic multiple myeloma: A case report

and review of the literature . Oncol Lett 2013 ; 5 : 218 – 20 .

2 Maskin LP , Díaz MF , Hlavnicka A et al . Gastrointestinal bleeding

secondary to multiple gastric plasmacytoma . Am J Clin Oncol

2008 ; 31 : 100 – 1 .

3 Nakajima K , Sueki Y , Koshiishi M et al . Gastric invasion of multiple

myeloma presenting as gastrointestinal bleeding . Int J Hematol

2015 ; 101 : 1 – 2 .

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