It is widely known that long-term use of anthranoid-containing laxatives
      is the cause of melanosis coli. We describe a case of melanosis coli,
      which occurred in a 39-year-old liver transplant patient who took an
      over-the-counter product containing aloe, rheum and frangula. The typical
      brownish pigmentation of the colonic mucosa developed in a period of ten
      months. The anthranoid medication was stopped and follow-up colonoscopy
      one year later showed normal looking mucosa once more. However, in
      contrast to previous examinations, a sessile polypoid lesion was found in
      the transverse colon. Histology showed tubulovillous adenoma with
      extensive low-grade dysplasia. Since there have been preliminary reports
      suggesting a possible role of anthranoid-containing laxatives in the
      development of colorectal adenomas and cancer, their use should be
      discouraged

Buuren, H.R. (Henk) van

Krijger, R.R. (Ronald) de

Willems, M.

Willems, M

van Buuren, Henk

de Krijger, Ronald

NARCIS 

Anthranoid self-medication causing rapid development of melanosis coli

Erasmus University Digital Repository

A B S T R A C TIt is widely known that long-term use of anthranoid-containing laxatives is the cause of melanosis coli. Wedescribe a case of melanosis coli, which occurred in a39-year-old liver transplant patient who took an over-the-counter product containing aloe, rheum and frangula.The typical brownish pigmentation of the colonic mucosadeveloped in a period of ten months. The anthranoidmedication was stopped and follow-up colonoscopy oneyear later showed normal looking mucosa once more.However, in contrast to previous examinations, a sessilepolypoid lesion was found in the transverse colon.Histology showed tubulovillous adenoma with extensivelow-grade dysplasia. Since there have been preliminaryreports suggesting a possible role of anthranoid-containinglaxatives in the development of colorectal adenomas andcancer, their use should be discouraged.I N T R O D U C T I O NAnthranoid-containing laxatives frequently cause melanosiscoli, a condition which may be associated with an increasedrisk for colorectal cancer.1,2 These products are widely usedand self-administered for constipation. Few studies haveactually documented how long it takes before the coloniclesions develop.3 We detected melanosis coli in a patient tenmonths after he started to use an anthranoid-containinglaxative.C A S E  R E P O R TA 39-year-old patient underwent liver transplantation in1999 for end-stage primary sclerosing cholangitis. Since1977 he was also known to suffer from ulcerative colitiswhich had been clinically quiescent during recent years.In January 2000 surveillance colonoscopy revealed nosignificant abnormalities. In particular, no abnormalmucosal discoloration was noted (figure 1) and colonichistology was normal. In contrast, in January 2001 a furthercolonoscopy showed a marked brownish pigmentation ofthe mucosa of the entire colon, compatible with melanosiscoli (figure 2). Macrophages loaded with pigment werefound in all biopsies taken from different areas of the colon(figure 3). At the time of the last examination he was beingtreated with mesalazine, tacrolimus, etidronate, vitamin D,psyllium and occasionally with polyethylene glycol (thelast two because of constipation). Further medical historyrevealed that for the last ten months he had been takingtwo tablets of another product called ‘Rheum Frangula’daily. This product consists of aloe, rheum and frangula,all three anthranoid-containing laxatives, which areknown to be the cause of melanosis coli. We advisedour patient to stop taking this product. A year latercolonoscopy showed normal looking mucosa; biopsiesshowed no evidence of melanosis. However, in contrast toprevious examinations, a large sessile polypoid lesion wasfound in the transverse colon. Histological examinationshowed tubulovillous adenoma with extensive low-gradedysplasia. The patient was listed to undergo total colectomyin the near future. J A N U A R Y  2 0 0 3 ,  V O L .  6 1 ,  N O .  1© 2003 Van Zuiden Communications B.V. All rights reserved.22Anthranoid self-medication causing rapiddevelopment of melanosis coliM. Willems1, H.R. van Buuren1*, R. de Krijger2Departments of 1Gastroenterology and Hepatology (Ca 415), and 2Pathology, Erasmus MedicalCentre, PO Box 2040, 3000 CA Rotterdam, the Netherlands, tel.: +31 (0)10-463 37 93, fax: +31 (0)10-436 59 16, e-mail: vanbuuren@mdl.azr.nl, * corresponding authorC A S E  R E P O R TWillems, et al. Anthranoid self-medication causing rapid development of melanosis coli.J A N U A R Y  2 0 0 3 ,  V O L .  6 1 ,  N O .  123Figure 1Colonoscopy in January 2000 showing a normal appearingmucosaFigure 2Colonoscopy in January 2001 showing diffuse brownishpigmentation of the colonic mucosa compatible withpseudomelanosis coliFigure 3Colonic biopsy showing macrophages loaded with pigment (haematoxylin and eosin staining, 40x)D I S C U S S I O NIt is well known that anthranoid-containing laxatives frequently cause melanosis coli, a disease entity which canbe identified by a brownish pigmentation of the colonicmucosa. Long-term use of anthranoids is generallybelieved to be necessary to cause melanosis coli.However, as long as 50 years ago it was documentedthat this condition can develop within periods varyingfrom only 3 to 13 months.3 A clearly established pictureof melanosis coli was found in our patient after tenmonths. Anthranoid-containing herbal laxatives damage epithelial cells, leading to changes in absorption, secretion and motility.4 They can induce cell loss, shortening of mucosal crypts and increased cell proliferation.2 It remains controversial whether melanosiscoli is associated with an increased risk for colorectalcancer, as reported by Siegers et al.1 Other studies, however, have either failed to confirm this5 or found anincreased risk for colorectal adenomas but not for cancer.6Our patient clearly was at risk for developing colonicneoplasm considering his long-standing ulcerative colitisin association with primary sclerosing cholangitis and theuse of immunosuppressive medication after liver trans-plantation.7,8 Therefore, the role of the short-term use ofthe laxative in the development of this patient’s adenomais highly speculative. From a practical point of view, it maybe wise and prudent to discourage the use of anthranoid-containing laxatives, also considering the availability ofsafe alternatives. R E F E R E N C E S1. Siegers CP, Hertzberg-Lottin E von, Otte M, Schneider B. Anthranoidlaxative abuse, a risk for colorectal cancer? Gut 1993;34:1099-101.2. Gorkom BAP van, Karrenbeld A, Sluis T van der, Koudstaal J, Vries EGEde, Kleibeuker JH. Influence of highly purified senna extract on colonicepithelium. Digestion 2000;61:113-20.3. Speare GS. Melanosis coli. Experimental observations on its productionand elimination in twenty-three cases. Am J Surg 1951;82:631-6.4. Gorkom BAP van, Vries EGE de, Karrenbeld A, Kleibeuker JH. Anthranoidlaxatives and their potential carcinogenic effects. Aliment PharmacolTher 1999;13:443-52.5. Kune GA, Kune S, Field B, Watson LF. The role of chronic constipation,diarrhea, and laxative use in the etiology of large-bowel cancer. Data fromthe Melbourne Colorectal Cancer Study. Dis Colon Rectum 1988;31:507-12.6. Nusko G, Schneider B, Muller G, Kusche J, Hahn EG. Retrospective studyon laxative use and melanosis coli as risk factors for colorectal neoplasma.Pharmacology 1993;47(suppl 1):234-41. 7. Shetty K, Rybicki L, Brzezinski A, Carey WD, Lahsner BA. The risk forcancer or dysplasia in ulcerative colitis patients with primary sclerosingcholangitis. Am J Gastroenterol 1999;94:1643-9.8. Haagsma EB, Hagens VE, Schaapveld M, et al. Increased cancer riskafter liver transplantation: a population-based study. J Hepatol2001;34:84-91.J A N U A R Y  2 0 0 3 ,  V O L .  6 1 ,  N O .  1Willems, et al. Anthranoid self-medication causing rapid development of melanosis coli.24

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