A 73-year-old man with a medical history of ischemic cardiomyopathy and atrial fibrillation,
who was being treated with digoxin, bisoprolol, and warfarin, underwent a colonoscopy
for colorectal cancer screening in April 2013. A 20-mm pedunculated polyp was excised
from the ascending colon using a snare after injection of epinephrine in the stalk,
and a 30-mm pedunculated polyp was excised, using a similar method, from the sigmoid
colon; no other lesions were found. Pathologic analysis showed a low grade dysplastic
adenoma in the former and a low grade dysplastic adenoma with areas of high grade
dysplasia, with free margins, in the latter. The patient did not experience any immediate
complications and remained completely asymptomatic.
A follow-up colonoscopy was performed 1 year later. Multiple round and smooth subepithelial
nodules, with normal overlying mucosa, suggestive of pneumatosis cystoides intestinalis
([Fig. 1 a – c]), were observed in the ascending colon. With a biopsy forceps and a needle, we deflated
some of these lesions, confirming the diagnosis ([Video 1]). Pathologic analysis showed some features of pneumatosis intestinalis with a cyst
centered in the muscularis mucosa/submucosa (disruption of the muscle was noted) ([Fig. 2]).
Fig. 1 a – c Pneumatosis cystoides intestinalis after screening colonoscopy: endoscopic views
of submucosal lesions found in the ascending colon in an area where polypectomy had
been done 1 year previously.
Fig. 2 Histological image showing features of pneumatosis intestinalis (hematoxylin and
eosin [H&E], x 100).
Video showing biopsy and deflation of nodules using forceps and an endoscopic needle.
The pathogenesis of this condition is poorly understood [1]
[2]. Traumatic injury of the mucosa caused by polypectomy could allow intraluminal gas
to pass through the wall of the colon. This “mechanical theory” [1] is not widely accepted as the cause of pneumatosis intestinalis; however, we conclude
that it is the best explanation in this case since the gaseous cysts became evident
only after polypectomy in the same region of the colon.
Endoscopy_UCTN_Code_CCL_1AD_2AJ
