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Family history was signifi cant for prostate cancer. His physical examination was signifi cant for mild epigastric tenderness. Initial laboratory data was signifi cant for hemoglobin of 9.1g/dL and hematocrit of 28.6%. A complete metabolic panel was normal. CT scan revealed metastases in the right cardiac ventricle, bilateral adrenal, left gluteal mass and pancreatic tail. Diff use mesenteric, celiac, external iliac and portal venous adenopathy was seen. Echocardiogram showed a mobile echodensity in the right ventricle. MRI of brain showed no masses. A repeat endoscopy revealed a large non-circumferential, non-pigmented, ulcerated gastric mass with stigmata of recent bleeding. Th e stomach biopsy showed sheets of loosely cohesive malignant polygonal cells consistent with malignant melanoma. HMB-45 and vimentin were positive. Th e patient denied any history of cancerous lesions of the skin. A complete examination of his skin, including oral and anal mucosa, showed no suspicious lesions, and fundoscopic examination of the eye was normal. He was diagnosed with metastatic gastric melanoma with an unknown primary. Unfortunately, patient refused further workup and returned to the correctional facility. Although more than 90% of melanomas have a cutaneous origin, occasionally it is discovered as a metastasis without evidence of a primary site. Th e incidence of metastatic malignant melanoma with an unknown primary (MUP) is 3.2 %. Th e frequently asymptomatic character of MUP explains why it oft en eludes detection. However, symptoms may include gastrointestinal bleeding, abdominal pain, nausea, and anorexia. Diagnosis requires careful inspection of the mucosa for metastatic lesions and biopsy with special immunohistochemical stains (HMB-45 and S100). Th is case is presented in view of its rare occurrence and the diffi culties in its diagnostic course. Early detection and surgical intervention is critical for long term cure, though overall prognosis is poor.

To twist or not to twist: a case of ERCP in situs inversus totalis