A 47 year old man was referred to a colorectal surgeon for a right hemicolectomy for management of right colon polyposis. Repeat colonoscopy demonstrated these 5-15 mm lesions extending from the hepatic flexure down to the cecum. The lesions are sessile, yellowish in hue, and seem to be covered with normal colonic epithelium. They are firm to probing. There is no pillow sign to suggest the soft composition of a lipoma.
The biopsy forceps is used here to unroof the lesion of its overlying mucosa revealing a cystic, almost marble-like appearance. The vault of the cecum is relatively spared, and the mucosa throughout the right colon and the cecum is otherwise entirely normal.
One of the lesions is snared for polypectomy. The base of the lesion is relatively unremarkable. The lesion itself was firm and could only be retrieved using a Roth basket. The lesion floated when placed in formalin, and could be transilluminated using the light at the endoscope tip. Pathologic findings revealed a fibrotic capsule around an air-filled cyst and was diagnostic of pneumatosis cystoides intestinalis.
Pneumatosis cystoides intestinalis is an uncommon condition associated with a broad seemingly unrelated spectrum of diseases such as Crohn's, intestinal ischemia, asthma, and diabetes. It can involve the stomach, the small bowel, and/or the colon. The colonic lesions are referred to as pneumatosis coli. It's cause is unknown. Pneumatosis cystoides intestinaliis is usually found incidentally, and usually causes no symptoms. In asymptomatic patients, no therapy is justified. Rarely, however, the condition can result in vomiting, bleeding, abdominal pain, or obstruction. A variety of therapies have been reported including hyperbaric oxygen, metronidazole, and surgery.
Brian Fennerty, M.D., Oregon Health and Science University