Speckled Duodenum – A Rare Case of Pseudomelanosis Duodeni

75-year-old ventilator-dependent female with chronic respiratory failure, stroke, gastrostomy tube and a mechanical aortic valve on coumadin presented with anemia secondary to melena. Esophagogastroduodenoscopy [1] performed didn't reveal the source of bleeding but showed an abnormal speckled brown pigmentation of the duodenal bulb extending down past the second portion (Figure 1). Duodenal biopsies showed chronic inflammation, foveolar metaplasia and Brunner's gland hyperplasia (Figure 2). Brown pigment in duodenal villous macrophages was negative for iron on Prussian blue stains.