Small bowel pigmentation

Question A 73-year-old male, referred by his GP with dyspepsia unresponsive to proton pump inhibitors. His past medical history included COPD, ischemic heart disease, Iron deficiency anaemia (IDA) investigated with colonoscopy and a colonic polyp removed 2012. In the absence of a clear treatable condition behind his IDA, his low Iron was treated with Iron supplement Ferrous Sulphate. His current medications included esmoeprazole, ranitidine, atorvastain, losartan, inhalers, and ferrous sulphate. He was a heavy smoker, with a history of alcohol excess in the past. On Iron tablet his blood test revealed a normocytic anaemia with a Hb of 126, normal LFTs, U&Es, Amylase and CRP of 2.5. There was no history of blood transfusion and serum ferritin was 14 prior to the Iron therapy. He underwent an upper GI endoscopy in March 2016 and this showed a mild gastritis, moderate amount of food residue and multiple speckled areas of red pigmentation in the duodenum: