S3055 Pseudomelanosis of the Small Intestines Masquerading as Small Bowel Ischemia

Abstract

Introduction: Pseudomelanosis of the small intestines is typically a benign and incidental finding during endoscopy, characterized by dark speckled mucosal pigmentation. We present a case a of new onset pseudomelanosis of the small intestine mistaken for mesenteric ischemia in patient with abdominal pain, weight loss, and anemia. Case Description/Methods: A 65-year-old female with medical history of systemic sclerosis, hypertension, chronic kidney disease stage four, coronary artery disease, and mechanical mitral valve replacement presented for evaluation of iron deficiency anemia and recurrent overt small intestinal bleeding in setting of chronic warfarin therapy. Single balloon enteroscopy eleven months prior demonstrated non-bleeding angioectasias throughout stomach and small bowel and otherwise normal appearing small bowel mucosa. Patient was referred for repeat small bowel enteroscopy in setting of continued anemia and interval weight loss, abdominal pain, and anorexia. Endoscopy demonstrated diffuse dusky mucosal changes in the entire visualized duodenum and jejunum. Due to concern for small bowel ischemia, patient was admitted for vascular evaluation. CT angiography ruled out mesenteric ischemia. Small bowel biopsies ultimately showed pseudomelanosis duodeni and jejuni. Discussion: Pseudomelanosis of the small intestines is rare but benign condition. It has been associated with co-morbidities including diabetes, hypertension, and chronic kidney disease and medications including supplemental iron, beta blockers, furosemide, hydralazine, and thiazides. Our case highlights the potential for pseudomelanosis of the small intestines in a medically complex patient to be mistaken for more sinister vascular disorders.Figure 1.: Single balloon enteroscopy a). Pseudomelanosis duodeni b). Pseudomelanosis jejuni c). Pseudomelanosis jejuni.