Introduction 

Intestinal pseudomelanosis is an uncommon condition, more frequently observed in the colon, with a prevalence of 10–15% in patients receiving iron supplementation, activated charcoal, or with chronic metabolic diseases. It is characterized by the accumulation of iron- and lipofuscin-derived pigments within macrophages of the lamina propria. Although benign, its diagnosis is important to differentiate it from serious pigmented pathologies. It has been associated with comorbidities such as hypertension, chronic kidney disease, or iron supplementation. Histological confirmation is key to avoid inappropriate management. 

Endoscopy 

A 78-year-old man with hypertension was referred from Primary Care for colorectal cancer screening due to a family history of polyposis. His last colonoscopy in 2019 revealed a spastic colon and dolichocolon. Complete colonoscopy with cecal intubation and distal ileum visualization was performed, showing areas of edematous mucosa with patchy dark pigmentation and villous atrophy. Ileal biopsies were taken. Histopathology confirmed ileal pseudomelanosis. Melanosis coli was also observed throughout the explored colon. 

Comments/Conclusions 

Ileal pseudomelanosis is very rare, and its endoscopic recognition may raise diagnostic doubts, especially due to its pigmented appearance, which can mimic serious conditions such as metastatic melanoma. Histology is essential for confirmation. Its association with melanosis coli and a history of chronic treatments supports its benign nature. No formal follow-up guidelines exist, but accurate identification allows avoidance of unnecessary tests or treatments, optimizing clinical management.