Melanosis ilei secondary to chronic iron supplementation

Melanosis ilei is an uncommon, benign condition characterized by dark pigmentation of the terminal ileal mucosa. Usually asymptomatic, it is frequently found incidentally during endoscopic examination. We report a 42-year-old female with iron deficiency anaemia receiving oral iron treatment who had a colonoscopy and gastroscopy as part of anaemia workup. The results of the colonoscopy and gastroscopy were uneventful, but deep intubation of the terminal ileum showed many distinct to confluent dark brown pigmented areas that seemed peppered and speckled. Melanosis ilei was confirmed by the histopathology of ileal samples, which showed pigment-laden macrophages in the lamina propria. This etiology was attributed to long-term iron supplementation. Recognition of the characteristic endoscopic and histopathologic features of melanosis ilei is important to prevent misdiagnosis and unnecessary interventions. LEARNING POINTS: Recognizing melanosis ilei as a benign consequence of chronic iron therapy provides a critical diagnostic shortcut, allowing internists to confidently differentiate 'pseudomelanosis' from life-threatening intestinal ischemia and avoid the morbidity associated with unnecessary surgical consultations or aggressive workups.