Pneumatosis Intestinalis. The Question Is To Be or Not To Be – A Polyp!

Abstract

Purpose: 57 year old male with history of diabetes and hyperlipidemia presented with abdominal distension and flatulence of several months duration. Initial colonoscopy by the referring gastroenterologist revealed multiple large, broad based, transverse colon polyps. Snare polypectomy was deferred due to concerns regarding diagnosis and potential complications. Laparoscopic resection vs. endoscopic resection by a skilled endoscopist was discussed with the patient who opted for the latter. Colonoscopy performed at our institution revealed many 5–25 mm, sub-mucosal lesions. The morphology was that of a distinct raised globular lesion or a confluent multilobulated mass (Fig. 1). The endoscopic impression was pneumatosis coli. The largest polyp was partially snared to remove the mucosa and well biopsies were taken to get deeper tissue. Biopsies revealed numerous gas filled cysts in mucosa and sub mucosa, lined by epitheliod histiocytes (Fig. 2).FigureFigurePneumatosis intestinalis is characterized by multiple gas-filled intamural cysts in the small or large bowel. It may be primary or secondary due to peptic ulcers, IBD, feeding jejunostomy, ruptured diverticuli, clostridium difficile, AIDS enterocolitides, COPD, mechanical ventilation, post endoscopy and intestinal ischemia. This finding may be incidental on endoscopy or routine imaging. Symptomatic patients may present with diarrhea, hematochezia, abdominal pain, distension or flatulence. Hyperbaric oxygen treatment and antibiotics are helpful in some instances. However, in cases of intestinal ischemia and perforation, pneumatosis is an ominous sign and emergent surgery is indicated. Conclusion: Our patient had persistent irritable bowel symptoms likely unrelated to pneumatosis. Endoscopic recognition and confirmatory biopsies avoided an unnecessary surgical resection, for an otherwise benign condition.[figure1][figure2]