Unusual Large Nodules in the Colon

Question: A 73-year-old-woman with nontuberculous mycobacterial pulmonary disease who was receiving antibiotic treatment presented with a 2-day history of progressive abdominal pain. Physical examination revealed mild tenderness in the right upper quadrant, without guarding or rebound. Laboratory tests were unremarkable except the C-reactive protein level was 2.9 mg/dL. Computed tomography of the abdomen showed grape-like clusters of air pockets within the colonic wall. Colonoscopy revealed multiple, variably sized, submucosal nodules in the ascending and transverse colon, with some protruding and almost entirely obstructing the colonic lumen (Figure A and B; Video 1). Narrow-band imaging magnified endoscopy revealed a normal surface pattern with dilated blood vessels and spots without irregularities (Figure C; Video 1). What is the diagnosis and how should the patient be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. These findings were consistent with a diagnosis of pneumatosis cystoides coli (PCC). The large nodules of PCC were incised with an endoscopic needle knife, and they collapsed without releasing any fluid (Figure D; Video 2). The presence of multiple, multilocular, thin-walled, transparent, gas-filled cysts in the submucosa was confirmed (Figure E and F; Video 2). Furthermore, histologic findings of the biopsy specimens revealed the characteristic features of PCC, multiple air-filled cysts of various size in the submucosa. The patient’s symptoms resolved after the procedure without complications. PCC is a rare condition characterized by the presence of gas-filled cysts in the submucosa and/or subserosa. The pathogenesis of PCC is poorly understood and is probably multifactorial. Several putative mechanisms are being discussed. Among them, the 3 most well-accepted hypotheses are the pulmonary, mechanical, and bacterial theories.1St Peter S.D. Abbas M.A. Kelly K.A. The spectrum of pneumatosis intestinalis.Arch Surg. 2003; 138: 68-75Crossref PubMed Scopus (274) Google Scholar Because of the asymptomatic or nonspecific symptoms, the diagnosis of PCC mainly depends on computed tomography, colonoscopy, and endoscopic ultrasound. The appropriate treatment depends on the complications and the underlying causes of PCC. Conservative management is recommended in most patients, including observation, bowel rest, hyperbaric oxygen therapy, and endoscopic treatment.1St Peter S.D. Abbas M.A. Kelly K.A. The spectrum of pneumatosis intestinalis.Arch Surg. 2003; 138: 68-75Crossref PubMed Scopus (274) Google Scholar Endoscopic fine-needle aspiration is useful for the treatment of PCC.2Takahashi K. Fujiya M. Ueno N. et al.Endoscopic fine-needle aspiration is useful for the treatment of pneumatosis cystoides intestinalis with intussusception.Am J Gastroenterol. 2019; 114: 13Crossref PubMed Scopus (8) Google Scholar,3Zimmer V. Schnabel P.A. Lammert F. A flat tire in the colon.Gastroenterology. 2018; 154: e8-e9Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar It can also be used to diagnose PCC because it confirms the presence of gas-filled cysts via direct observation. Endoscopic techniques include the “puncture and cytology” and the “clear water filling and puncture” techniques.3Zimmer V. Schnabel P.A. Lammert F. A flat tire in the colon.Gastroenterology. 2018; 154: e8-e9Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar For the large lesions, as in this case, composed of multilocular cysts, endoscopic mucosal incision was considered more effective than puncture with a needle. Surgery is indicated for patients who do not respond to medical therapy or who develop life-threatening complications such as bowel obstruction, perforation, peritonitis, or necrosis.1St Peter S.D. Abbas M.A. Kelly K.A. The spectrum of pneumatosis intestinalis.Arch Surg. 2003; 138: 68-75Crossref PubMed Scopus (274) Google Scholar However, endoscopic mucosal incision may be an alternative method for PCC with obstruction. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiMDQxMjFmMzA4OTk2ODI3OGFlZjNlMjkzYWJiNTEwZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjkxNDUxOTA4fQ.B80e4ufr4Ascm-oVQeDrJpV0xbfuJqmW1XJW4togytQ4ECXeUJ3opgZp-DU74Y4stTezVGhjZMBN9zyz3ue_mVEuneBpNb40k8BoJkFubDGSqjHUQXsGhOIOrLYndbPkUnVTmJL1VW-eVgPE3u6gbi4SgmYuT1-AvHjwUJziN4F1DzKfGHGwSp0swdcsVe9ab504FU3FU-LB20uYpk6K44Dn15JrxJv-KbbkiL004UHJHQ_f5BvkEfwuGsQpzBO5m_hDapoPbOvQv-6NvnURW9wCaJD4ZpI6t5eqsxrqUSyoRhR6Z_bzOqB4YGcVduhdJzpC9zi4Ck-CosNOQsXdOw Download .mp4 (7.79 MB) Help with .mp4 files Video 1eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4MTkwM2JlMjcyODY5Y2MyNzk5MWQ5MzM4ZTc1M2Q1MiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjkxNDUxOTA4fQ.CRYUDfRORd0nixXTi7PY4dyxic85cph_ne6_Qq79CkyNX8ePHmrPSA_ZuF6IDA9MAYVS2ydL5NI9WN5a1n_PmBsBLacis3Ej1OHoWc4eg2mYjJE77KRM5CyeGbo7uQYYyP0Epl1I5c5b5S0l9Uk7m0xqB4v1r-8N3nbGMd-JCuLfgm2nyqDaGdrodBP3YXWsmy-beuaWPFjoaiulpioaOTiTeSVk7lc-dL_JZYtHYWedvyZvQevSZl34tHJbg7JAYDJ3FxBpEoLG0aRZdzMkg_Hs21TqdMolTW7Dc12qgnIkfl7mtl-FF47SCc62MVTsdFs7-p5vQwI_WsXlCMlf-g Download .mp4 (7.47 MB) Help with .mp4 files Video 2