Pseudomelanosis Gastri

Abstract

Pigmented stains are frequently seen during endoscopy, especially in the colon in patients using anthraquinone-containing laxatives. Occasionally these are seen the duodenum, ileum and even less rare are pigmented stains in the stomach. The etiology of these pigmented stains in the stomach are unknown, but several case reports have shown association with certain medications and medical conditions. Here we present two cases of pseudomelanosis gastrii. Case 1: 81 y/o F with was seen in the clinic for intermittent solid food dysphagia and was scheduled for an outpatient EGD. PMH: GERD, hypothyroid, COPD, hypertension, arthritis MEDS: Acetaminophen-codeine, Albuterol, Clonidine, Dipyridamole, Hydralazine, Levothyroxine, Lisinopril, Metoprolol, Omeprazole, verapamil SHx: no smoking, drinking or drug use. Labs: WNL. Prior Endoscopy: pigmented stains noted in the stomach and duodenum Case 2: 91 y/o M admitted to the hospital for epigastric pain, nausea and emesis. PMH: GERD, Barrett's esophagus, hypertension, CKD, Myelodysplastic syndrome, prostate CA MEDS: Nifedipine, Hydralazine, Pantoprazole, Polyethylene Glycol, Ondansetron, Pravastatin, Loratidine, Gabapentin SHx: 10 pack years history, quit 50 years prior, one beer per month. Labs: GFR- 41, Hgb 9.5, Plt- 128. Prior endoscopy: Normal Pathology: In both cases the macrophages in the lamina propria were distended by dark pigmented granules that had the appearance suggesting melanin, hemosiderin or india ink. It may represent ferrous sulfide as it only faintly stains for iron stain as seen in our patient. Pigmented stains are commonly encountered during colonoscopy in patients on anthraquinone-containing laxatives, melanosis coli, where lipofusion is found in macrophages in the lamina propria. Pseudomelanosis gastrii appears to be a different entity not associated with laxatives. While the etiology remains unknown, it is most frequently found in the setting of upper GI hemorrhage, chronic renal insufficiency diabetes mellitus and/or medications such as, ferrous sulfate, hydralazine, furosemide and beta-blockers. In our two cases both were elderly, had hypertension and had GERD. They were also both on hydralazine, PPI's, and calcium channel blockers. This is similar medication use and medical comorbidities as the few case reports published. However, neither of our patients had diabetes and only one had chronic renal insufficiency. Patient in case 1 is doing well with resolution of her dysphagia after under going an esophageal dilation. Patient in case 2 died from underlying coronary heart disease three months after the procedure.Figure 1Figure 2Figure 3