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Osmotic Laxatives: an Unusual Cause of Melanosis Coli? 3 JCC Open (2014) 2, 1—3 Disponible en ligne sur ScienceDirect www.sciencedirect.com CASE REPORT Osmotic laxatives: An unusual cause of melanosis coli? Laxatifs osmotiques : une cause inhabituelle de mélanose colique ? a,∗,b a,b a,b R. Ennaifer , H. Romdhane , N. Elleuch , a,b a,b a,b R. Hefaiedh , H. Ben Nejma , N. Belhadj a Department of Hepato-gastro-enterology, Mongi Slim Hospital, La Marsa, Tunis, Tunisia b Université de Tunis El Manar, faculté de médecine de Tunis, Tunis, Tunisia Received 10 October 2013; accepted 25 November 2013 Melanosis coli refers to an abnormal brown or black pigmentation of colonic mucosa caused by the presence of lipofuscin in macrophage within the lamina propria [1]. This condition is not uncommon in patients investigated for long term constipation, often in conjunction with a history of chronic use of the anthraquinone family of laxatives [2]. However, a history of such laxative use has not been confirmed in all patients with these endoscopic and histologic findings [3]. Below, we describe two cases of melanosis coli in women with history of chronic constipation who never used anthraquinone laxatives. Case reports Case 1 A 19 year-old female patient visited our department for long history of chronic consti- pation. She had no past medical history. Her medication consisted of osmotic laxatives, but she never used laxatives containing anthranoid or herbs. Laboratory investigations were normal, without anemia, azotemia, hypokalemia or hypercalcemia. Colonic exami- nation disclosed several black colored geographic mucosal pigmentations in the caecum, while the rest of the colon and the terminal ileum showed normal findings (Fig. 1). Biopsy was performed on the pigment deposition and microscopic examination disclosed abundant pigment containing macrophages at the lamina propria using hematoxylin-eosin stain, compatible with melanosis (Fig. 2). After the diagnosis of melanosis coli, laxative ∗ Corresponding author. E-mail address: [email protected] (R. Ennaifer). http://dx.doi.org/10.1016/j.jcco.2013.11.001 2212-0149/© 2014 Elsevier Masson SAS. All rights reserved. 2 R. Ennaifer et al. dark pigment is produced by the breakdown of apoptotic colonic epithelial cells [4]. Classically, melanosis coli has been linked to chronic laxative use, most commonly anthraquinones [1,2,4]. They appear to damage the colonic epithelial cells causing irreversible injury to some organelles, these latter can be sequestrated in macrophage were digestion to residual lipofuscin bodies results [5]. It is considered as a benign lesion that can disappear if the use of anthraquinone is discontinued [4]. However, melanosis coli can be observed in patients without a history of anthraquinone use. One study involving 38 patients showed that colonic epithelial apoptosis was increased in melanosis coli but the majority of cases were not associated with laxative use, suggesting that melanosis is a non-specific marker of increased apoptosis with many possible causes, of which the use of anthraquinone laxatives is only one [3]. Moreover, another report disclosed 25 patients with Figure 1. a: colonoscopic view of melanosis coli; b: diffuse dark- inflammatory bowel disease and melanosis coli, of whom brown punctuate pigmentations in the coecum mucosa. only 5 had documented laxative use [6]. Intestinal stasis in patients with constipation, as well as an impairment of motor function in the colon has formerly been suggested treatment was discontinued and the follow-up colonoscopy as a cause of melanosis coli but was not confirmed [7]. Yet, performed 1 year later disclosed the same findings in the caecum. no cases of melanosis coli induced by osmotic laxative have been reported. Indeed, melanosis can also affect various Case 2 part of the gastro-intestinal tract: duodenum, jenjunum and ileum but less frequently than the colon [8]. The reported A 38 year-old female complained of abdominal pain and pigments in these cases included iron sulfide, hemosiderin, constipation evolving for 6 months. She never used any med- charcoal and silicates of aluminium [8]. This localization is ication, except osmotic laxative during a few weeks. In not associated with laxatives use, and possible mechanisms laboratory findings, blood cell counts and blood chemistry of developing intestinal melanosis could be the release of were normal. Colonoscopy showed dark pigmentation of material after digestion, taken up by macrophages of the the caecum, looking like reptilian skin. Biopsy treated with gut [8]. Hemosiderin pigment detected in the ileum and a standard hematoxylin-eosin stain showed lamina propria duodenum has been related to intermittent bleeding or macrophages filled with brown colored pigment granules chronic oral iron ingestion, while aluminium and silicon consistent with a diagnosis of melanosis coli. containing compounds can be detected in food additives or medicine [5]. In our case, two hypotheses can be proposed Discussion about how melanosis was found in the colon in the absence of anthraquinones use: the first it that osmotic laxative contains materials reabsorbed by macrophages of the gut, Melanosis coli is an abnormal brown or black pigmentation the second is that chronic constipation or osmotic laxative of the colonic mucosa caused by the presence of lipo- increase colonic epithelial apoptosis. The persistence of fuscin in macrophage within the lamina propria [1]. This melanosis coli 1 year after osmotic laxative withdrawal is in favor of the role of chronic constipation. Conclusion As reported in the rest of gastro-intestinal tract, melanosis coli can be observed in patient without history of anthra- quinones use. Other causes, such as ingestion of osmotic laxatives or chronic constipation can be involved. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References Figure 2. Colonic mucosa: macrophages containing pigment in [1] Lestina LS. An unusual case of melanosis coli. Gastrointest the lamina propria (haematoxylin and eosin stain, X400). Endosc 2001;54:119—21. Osmotic laxatives: An unusual cause of melanosis coli? 3 [2] Batistatou A, Panelos J, Agnantis NJ. Melanosis intestini: case [6] Pardi DS, Tremaine WJ, Rothenberg HJ, Batts KP. Melanosis report. Diagn Pathol 2006;1:3. coli in inflammatory bowel disease. J Clin Gastroenterol [3] Byers RJ, Marsh P, Parkinson D, Haboubi NY. Melanosis coli asso- 1998;26:167—70. ciated with an increase in colonic epithelial apoptosis and not [7] Badiali D, Marcheggiano A, Pallone F, Paoluzi P, Bausano G, Ian- with laxative use. Histopathology 1997;30:160—4. noni C, et al. Melanosis of the rectum in patients with chronic [4] Shazia A, Gunaratnam NT. Melanosis Coli. N Engl J Med constipation. Dis Colon Rectum 1985;28:241—5. 2003;349:1349. [8] Cha JM, Lee JI, Joo KR, Jung SW, Shin HP. Melanosis ilei asso- [5] Freeman HJ. ‘‘Melanosis’’ in the small and large intestine. World ciated with chronic ingestion of oral iron. Gut Liver 2009;3: J Gastroenterol 2008;14:4296—9. 315—7..
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