INTRODUCTION: Pigmentation of the lower gastrointestinal tract called melanosis coli is a commonly encountered endoscopic finding. A similar pattern of pigmentation called pseudomelanosis is sometimes encountered during upper GI endoscopies. Duodenum is the most commonly reported site for pseudomelanosis, but there have been limited number of reported cases of gastric pseudomelanosis. CASE DESCRIPTION/METHODS: We present a case of 71 year old male with history of iron deficiency anemia, coronary artery disease, congestive heart failure, chronic kidney disease, hypertension, gout and hyperlipidemia who presented for GI endoscopy to evaluate his anemia. His medications included torsemide, hydralazine, ferrous sulfate, clopidogrel, pantoprazole, febuxostat, atorvastatin, amlodipine, isosorbide mononitrate, bisoprolol, irbesartan, citalopram, doxazosin and oxybutynin. Esophagogastroduodenoscopy (EGD) revealed a 3 mm dark spot in the antrum which was biopsied (Figure 1). Similar pigmentation was seen in the duodenum as well (Figure 2). Pathology revealed benign gastric mucosa with histological pattern of pseudomelanosis. Rest of the gastric mucosa was benign with non-specific chronic inflammation. Additional endoscopic findings observed were a linear pattern of mild erythema in the gastric antrum which was consistent with endoscopic appearance of gastric antral vascular ectasia. No active bleeding or oozing was observed. Rest of the EGD, as well as colonoscopy was unremarkable except for multiple small colon polyps. DISCUSSION: The exact etiopathogenesis of this rare entity remains unclear and various mechanisms have been proposed for this pigmentation pattern. Iron supplementation or upper GI bleeding leading to abnormal iron accumulation in macrophages of lamina propria has been proposed as a possible mechanism. Results of electron probe X-ray identified the role of sulfur containing compounds in causing accumulation of this pigment. Conditions associated with pseudomelanosis are CKD, hypertension, gastric hemorrhage and diabetes. Medications such hydralazine, thiazide, furosemide, Iron sulfate, methyldopa and propranolol have been shown to be associated with it. Sulfur containing drugs (such as hydralazine, furosemide and hydrochlorothiazide) are worth mentioning, since sulfur is shown to promote pigment deposition. The clinical significance, treatment and follow up of this rare condition is still unknown. Furthermore, no malignant transformation or long term complications have been reported so far.