Melanosis duodeni

Positive blood cultures growing Staphylococcus epider­

midis and Propionibacterium species were considered to rep­resent skin contaminants (15 among the 264 cultures on uppergastrointestinal endoscopy patients).DISCUSSION It is probably safe to state that upper gastrointes­tinal endoscopy is not associated with an increased frequencyof bacteremia in the usual patient. It was thought that thetrauma, especially of the pharynx, resulting from the passageof the fiberoptic 'scope, might induce bacteremia; however,this did not prove to be the case. Further work is needed toclarify the question of bacteremia after manipulation of thepancreatic ductor biliary tree because bacterial infection in anobstructed duct would appear to be a potential setting for thedevelopment of bacteremia.

Colonoscopy, on the other hand, appears to carry a some­what greater hazard of bacteremia, and special considerationto this matter is indicated when patients with valvular heartdisease or those on an immunosuppressant regimen are ex­amined.

The transient nature of the bacteremia in these patients maybe a reflection of the adequate removal of the bacteria by thereticuloendothelial system of the liver. Therefore, neitherupper nor lower gastrointestinal endoscopy imposes an unduehazard for the average patient. Special precautions should betaken - and possibly these procedures should be avoided­in patients in whom the consequences of bacteremia might beserious.

REFERENCES1. SLADE N: Bacteriaemia and septicaemia after urological operations. Proc R

Soc Med 51:331,19582. COBE HM: Transitory bacteremia. Oral Surg, Oral Med & Oral Path 7:609,

19543. RICHARDS jH: Bacteremia following irritation of foci of infection. lAMA

99:1496, 19324. FELIX jE, ROSEN 5, App GR: Detection of bacteremia afterthe use of an oral

irrigation device in subjects with periodontitis. Periodonto/42:785, 19715. LEFROCK jL, ELLIS CA, TURCHIK jB, WEINSTEIN L: Transient bacteremia

associated with sigmoidoscopy. N Engl I Med 289:467,19736. BUCHMAN E, BERGLUND EM: Bacteremia following sigmoidoscopy. Am

Heart I 60:863, 19607. UNTERMAN 0, MILBERG MB, KRANIS M: Evaluation of blood cultures after

sigmoidoscopy. N Engl I Med 257:773,19578. LEFROCK jL, ELLIS CA, KLAINER AS, WEINSTEIN L: Transient bacteremia

associated with barium enema. Arch Int Med 136:835, 19759. GREENE WH, MOODY M, HARTLEY R, EFFMAN E, AISNERj, YOUNG VM,

WIERNIK PH: Esophagoscopy as a source of Pseudomonas aeruginosasepsis in patients with acute leukemia: the need for sterilization of endo­scopes. Gastroenterology 67:912, 1974

10. COWAN ST, STEEL Kj: Manual for the Identification of Medical Bacteria.Cambridge (England), Cambridge University Press, 1965

of specialnoteMelanosis duodeni

William M. Bisordi, MDMartin S. Kleinman, MD*

University of RochesterSchool of Medicine and Dentistry

and Gastroenterology UnitStrong Memorial Hospital

Rochester, New York

The accumulation of black pigment in the colonic mucosawas first described in 1829' and has been extensivelyreviewed. 2 Melanin pigmentation has been classically de­scribed in the colon, but there are reports of pigment occurringin the appendix, mesenteric lymph nodes3, ileum', and possi­bly the esophagus.s We recently stud ied a patient who had thesurprising finding of pigment deposition in the villi of theduodenal mucosa. A careful search of the world's literaturefailed to reveal a similar case.CASE REPORT A 43-year-old insulin-dependent diabeticblack man with chronic renal failure was being treated bychronic dialysis at Strong Memorial Hospital. Gastroen­terologic consultation was requested to evaluate intermittentepisodes of abdominal pain suggestive of duodenal ulcer. Atendoscopy (Olympus GIF-D2) no ulcer was seen. Theduodenal bulb was friable. The folds were thickened, and apeculiar deposition of pigment in the duodenal mucosa wasobserved. The entire mucosa beyond the bulb in the secondpart of the duodenum had a "peppered" appearance. (Figure

1). Multiple biopsy specimens were taken. The esophagus andstomach were normal.

The rectal mucosa showed no signs of melanosis coli bysigmoidoscopic examination.

Barium contrast studies of the patient's stomach andduodenum were normal. The patient vigorously denied inges­tion of cathartics such as cascara. His only medications wereinsulin and, occasionally, liquid aluminum hydroxide gel tolower the serum phosphate.

The patient was given intensive antacid therapy with subse­quent improvement of his pain.

Sections of duodenal mucosa stained with hematoxylin­and-eosin (Figure 1) disclosed pigment deposited in the tips ofthe villi. Specific staining methods confirmed this pigment asmelanin.·Reprint requests: Martin 5. Kleinman, MD, Strong Memorial Hospital, 601Elmwood Avenue, Rochester, New York 14642.

Figure 1. Endoscopic photo­graph of the first portion of theduodenum (left). Note the pep­pered appearance of the duo­denal mucosa. The bleeding wascaused by biopsy. In this hema­toxylin-and-eosin section (40x) ofthe duodenal mucosa (right), thearrow points to a collection ofpigment just below the epithelialsurface.

VOLUME 23, NO.1, 1976 37

DISCUSSION Careful review of the literature has failed toreveal an example of melanin staining of the duodenum onsurgical, postmortem, or endoscopic evaluation. Pigmentdeposition in the rectum has been associated with the inges­tion of cathartics of the anthracine type and is thought to berelated to fecal stasis. The pa'tient herein described denied theuse of cathartics or the ingestion of unusual foods or homeremedies. The melanin pigment in the duodenal mucosa wasclearly extracellular, collecting in clumps below the epithelialsurface. The cause and clinical significance of this unusualfinding remains obscure.

Adenocarcinoma occurringin a hyperplastic gastric polypRemoval by electrosurgical polypectomy

John P. Papp, MD*Department of Internal Medicine

Michigan State Universityand Blodgett Memorial Hospital

Grand Rapids, Michigan

Julian I. Joseph, MDDepartment of Pathology

Mary's HospitalGrand Rapids, Michigan

Polyps of the stomach are rare.'-2 They may be benign ormalignant tumors, hyperplastic (regenerative), or composed ofectopic tissue. Hyperplastic polyps occur from 3 to 8 timesmore commonly than adenomatous polyps. Although thefrequency of associated malignancy has been reported to varyfrom 8% to 28%, malignancy occurring in a hyperplasticpolyp is said not to occur. 3- 4

This report descri bes partial gastric outlet obstruction due toa hyperplastic polyp. After removal by endoscopic elec­trosurgery, it was found that the polyp was partially composedof an adenocarcinoma without invasion into the stalk.CASE REPORT An 8S-year-old woman had had midepigastricpain and vomiting for 4 weeks before admission. Emesisoccurred 60 to 120 minutes after eating and relieved themidepigastric pain. Solid food increased her pain. She had lost10 pounds.

Physical examination revealed tenderness to palpation ofthe midepigastric area. A succussion splash was present. Theextent of liver dullness was 11 cm. There were no abdominalmasses. The hemoglobin was 12.S g, and the bematocrit was40%. An electrocardiogram showed first degree A-V block.Upper gastrointestinal barium radiography revealed a polypextending from the distal antrum through the pylorus into theduodenal bu Ib (Figure 1a).

Gastroscopy with the Olympus GIF endoscope showedsevere superficial gastritis throughout the stomach. A 1 cmstalk was seen to protrude into the duodenal bulb through thepylorus. The polyp stalk was grasped by biopsy forcep, and thepolyp head was brought into the antrum. The polyp wassnared, and the stalk was transected at setting 7 of theCameron-Miller electrocoagulation unit. The polyp was re­snared and withdrawn with the endoscope applying constantsuction. The external appearance was lobulated (Figure 1b).The stalk was light yellow and measured 0.8 cm. The mainportion of the polyp was light brown. On microscopic exam-

'Reprint requests: John P. Papp, MD, 2500 Oakwood Drive SE, Grand Rapids,Michigan 49506.

38

REFERENCES1. CRUVEILHEIR j: Cancer avec melanose. In Anatomic Patho/ogique du Corps

Humain, ). B. Bailliere (ed.), Paris, 1829. p. 62. WITIOESCH IH, JACKMAN RI, McDONALD jR: Melanosi coli: general

review and a study of 887 cases. J Dis Colon Rectum 1: 172, 19583. RODEN B: Melanosis coli - a pathological study. Its experimental produc­

tion in monkeys. J Med Sci 6:654, 19404. WON KH, RAMCHAND 5: Melanosis of the ileum: case report and electron

microscopic study. Am J Dig Dis 15:57, 19405. ANDREJAUKAS G: Rare cases of esophagitis with melanosis. Medicine 18:13,

1937

~:

FIGURE 1 (a) A polypoid lesion contrasted by barium is seen in theduodenal bulb. (b) A brown, lobulated polyp measuring 2.5 cmf x 2cm is seen arising from a light yellow stalk. (c) Carcinomatousinvolvement ofa hyperplastic polyp is seen (H & Ex 55). (d) Invasion ofthe stroma of the hyperplastic polyp by signet cell carcinoma (H & Ex430).

GASTROINTESTINAL ENDOSCOPY