Midwestern University, Mountain Vista Medical Center Spokane, WA, United States
Matthew Hillam, DO1, Preeyanka Sundar, MD, MPH1, Sara Ancello, DO2 1Midwestern University, Mountain Vista Medical Center, Mesa, AZ; 2Central Arizona Medical Associates, Mesa, AZ
Introduction: Pseudomelanosis duodeni (PD) is a condition in which excess stored iron is present in the mucosa of the proximal small bowel. PD is predominantly seen in females in the sixth and seventh decade of life and has been thought to be associated with chronic renal failure (CRF) on hemodialysis, diabetes mellitus, ferrous sulfate supplementation, sulfur-containing antihypertensive medications, gastric hemorrhage and some chronic illnesses.
Case Description/Methods: 58-year-old female with history of ESRD on peritoneal dialysis with history of failed renal transplant on cyclosporine and prednisone and severe acute on chronic normocytic anemia who receives erythropoietin every few weeks but does not take iron supplements. She was admitted for severe anemia with hemoglobin 4.8. Admission CT showed colitis and after serial transfusions, monitoring of hemoglobin and resuscitation, she underwent upper endoscopy showing gastritis and duodenal melanosis and colonoscopy showing normal terminal ileum, medium sized non-bleeding internal hemorrhoids and diverticulosis. Interestingly, the colonoscopy showed normal color of the terminal ileum and colonic mucosa, biopsies unremarkable. She had an EGD six months prior with gastric and duodenal biopsies for melena that showed pigment deposition in the lamina propria of the duodenum, more prominent in the tips of duodenum, no H pylori. She was discharged for outpatient follow up and video capsule endoscopy (VCE) if she continued to be anemic.
In clinic follow up she reported increased severity of chronic diarrhea with phosphate binders and was taking psyllium to regulate stools for the past 2 years. A VCE was pursued for persistent anemia with continued intermittent hematochezia and revealed duodenal melanosis but no signs of bleeding or hematin. Since then, she has had no further bleeding and her hemoglobin is being monitored with transfusions as needed.
Discussion: This case is interesting because PD has not been well documented in those on peritoneal dialysis, compared to those on hemodialysis. She also does not take medications that are known to cause PD. PD is a clinically rare condition without significant clinical symptoms and is benign. Due to the infrequent nature of this presentation, it is important to realize this is not related to laxative use like melanosis coli that is seen in the large intestine. Treatment consists of discontinuation of the medication associated with this condition.
Figure: A & B: Endoscopic images of second portion of duodenum showing pigmentation of the tips of the villi. C: Wireless capsule endoscopic image of proximal small bowel showing pigmentation of the tips of the villi. D: Pathology with dark pigmentation in the macrophages located in the lamina propria.
Disclosures: Matthew Hillam indicated no relevant financial relationships. Preeyanka Sundar indicated no relevant financial relationships. Sara Ancello indicated no relevant financial relationships.
Matthew Hillam, DO1, Preeyanka Sundar, MD, MPH1, Sara Ancello, DO2. P0940 - Beauty in the Small Bowels: Isolated Pseudomelanosis Duodeni, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.