A Case of Duodenal Pigmentation in a Patient with Upper Gastrointestinal Bleeding

Abstract

Case Report: This 67-year-old caucasian female with CAD, CHF, DM type 2, GERD, hypothyroidism, COPD, iron deficiency anemia, and multiple serrated adenomas throughout the colon presented to the ED with dizziness and lightheadedness. She had noticed intermittent black stools over the previous two months since being started on oral iron replacement. However, she described melena and maroon stools for two days prior to admission. She denied chest pain, shortness of breath, nausea, or vomiting. Our patient was found to be orthostatic on examination and lab values revealed acute worsening of known iron deficiency anemia. EGD was performed and revealed gastric AVM's and an antral ulcer (both coagulated using APC). In addition, upon intubation of the duodenum, punctate black pigmentation was identified diffusely throuought the duodenal bulb and second portion of the duodenum. Duodenal biopsies revealed “focal black pigment deposition into the lamina propria of the villi” and a negative iron stain. Further staining, including Fontana Masson with and without bleach, was performed. The pigment disappeared upon bleaching, which reflects that melanin is the probable origin. Discussion: These duodenal findings can possibly be attributed to “Pseudomelanosis duodeni” which is a rare endoscopic entitiy previously reported predominantly in African-American females in the sixth or seventh decade of life. Many reported patients are hypertensive (treated with hydralazine and propranolol in particular), diabetic, have chronic renal disease and have had upper gastrointestinal bleeding. Although exact composition of this pigmentation is unknown, it has been postulated to be melanin, a melanin-like substance, iron, hemosiderin, or lipofuscin. The full clinical significance of this finding has not been elucidated to date. In a patient with the above findings, we propose that he or she be evaluated other systemic entities which may be causative. First, the patient should undergo thorough dermatologic examination to assess for malignant melanoma, which has been described to metastasize to intestinal mucosa. Next, the patient should be evaluated for folic acid deficiency previously described to be associated with melanosis of the duodenum. Also, the patient's full medication history should be obtained (most importantly history of anti-hypertensive therapy).