3215 Duodenal Blackout: A Rare, Benign Endoscopic Finding

Abstract

INTRODUCTION: First described in 1976, psuedomelanosis is a rare, benign, incidental endoscopic finding most commonly seen in the duodenum. PD has been associated with chronic renal disease and the ingestion of various medications including hydralazine and iron supplements. Here we describe a classic presentation of an uncommon endoscopic abnormality. CASE DESCRIPTION/METHODS: A 66-year-old woman with decompensated cirrhosis, end stage renal disease, and hypertension presented to the hospital with hepatic encephalopathy and failure to thrive. Her medications included hydralazine and a history of iron supplementation. An esophagogastroduodenoscopy (EGD) performed for early satiety, weight loss and to initiate a liver transplant evaluation demonstrated diffuse mucosal hyperpigmentation in a striped pattern, predominantly in the second portion of the duodenum (Figure 1). Mucosal biopsy revealed an abundance of brown pigment deposition in the lamina propria (Figure 2) which was negative on Prussian blue stain and immunohistochemistry—consistent with a diagnosis of pseudomelanosis duodeni (PD). DISCUSSION: Despite its striking endoscopic appearance, there is no evidence that pseudomelanosis duodeni is associated with any progressive pathology. Though PD has been described anecdotally in case report and case series, little is known about the pathophysiology. Some have posited PD is related to iron or lipofuscin deposition in the lamina propria. PD has been associated with end-stage renal disease, hydralazine, thiazide diuretics, and iron supplementation. This case describes a classic presentation of PD with the archetypal imaging and histopathology to support the diagnosis of this uncommon condition.