Small bowel pseudomelanosis and oral iron therapy

Small bowel pseudomelanosis is a rarely reported clinical entity characterized by brown pigmentation of small bowel mucosa. The authors describe two cases, both with iron deficiency anemia, one of an 81-year-old female patient submitted for capsule endoscopy that revealed a brown pigmentation of all small bowel mucosa and another of an 81-year-old male whose retrograde double-balloon enteroscopy revealed a diffuse brown pattern of small bowel mucosa. Ileal biopsies confirmed intense iron deposition in the macrophages of the lamina propria. Both patients were on oral iron therapy and the second one had a previous double-balloon enteroscopy, 2 years earlier, which revealed only ileal angiodysplasias. These two cases demonstrate the importance of two new endoscopic methods for diagnosis of small bowel pseudomelanosis, the rarity of such an entity and its close relation with oral iron therapy.

Urgent capsule endoscopy is useful in severe obscure-overt gastrointestinal bleeding

AIM: With capsule endoscopy (CE) it is possible to examine the entire small bowel. The present study assessed the diagnostic yield of CE in severe obscure-overt gastrointestinal bleeding (OOGIB). METHODS: During a 3-year period, 15 capsule examinations (4.5% of all CE in a single institution) were carried out in 15 patients (11 men; mean age 69.9 +/- 20.1 years) with severe ongoing bleeding, defined as persistent melena and/or hematochezia, with hemodynamic instability and the need for significant red blood cell transfusion. CE was carried out after non-diagnostic standard upper and lower endoscopy. The mean time from admission until CE was 4.1 +/- 4.4 days (0-15 days). RESULTS: CE revealed active bleeding in seven patients and signs of recent bleeding in four. Etiology of bleeding was correctly diagnosed in 11 patients (73.3%) (portal hypertension enteropathy, three patients; subepithelial ulcerated lesion, two patients; angiodysplasia, two patients; jejunal ulcer with visible vessel, one patient; multiple small bowel ulcers, one patient; jejunal tumor, one patient; jejunal mucosa irregularity with adherent clot, one patient). One patient (6.7%) had active bleeding but no visible lesion. As a consequence of the capsule findings, specific therapeutic measures were undertaken in 11 patients (73.3%) with five managed conservatively, four endoscopically and two surgically. Two patients experienced bleeding recurrence. One of them, with a probable small bowel tumor, refused any other interventions. CONCLUSIONS: CE is useful in patients with severe OOGIB by providing positive findings in the majority of patients, with subsequent impact on therapeutic procedures.