University of California Irvine Orange, CA, United States
Samuel Ji, DO1, Peter H. Nguyen, MD1, Nathan Park, MD2, Rochelle Simoni, BSc3, Vamsi Vemireddy, MD4, Jason Samarasena, MD5 1University of California Irvine, Orange, CA; 2UC Irvine Medical Center, Orange, CA; 3UC Irivne, Orange, CA; 4University of California Irvine Medical Center, Orange, CA; 5University of California - Irvine, Orange, CA
Introduction: Pneumatosis cystoides intestinalis (PCI) is the presence of gas within the bowel wall. While the pathogenesis is unclear, it is usually found on diagnostic radiology exams incidentally and clinically asymptomatic. In extreme cases, it could be a sign of intestinal necrosis and require immediate surgical intervention. Here we present a case of PCI with an atypical, subacute symptomatology that was entirely diagnosed and managed endoscopically.
A 42-year-old woman with a history of PTSD and anxiety presented to her PCP and gastroenterologist for worsening constipation and bloating. She was referred for an EGD and colonoscopy. Her EGD was unremarkable, but her colonoscopy found three, firm nodules of about 10 mm in size located 35 cm from the anal verge and a small external hemorrhoid. Biopsies of the nodules were taken, which showed histologically unremarkable colonic mucosa. She was subsequently referred to Interventional GI for a endoscopic ultrasound (EUS) and possible resection.
The subsequent colonoscopy once again found the three lesions (one showed in top image). Methylene blue and saline were injected to attempt to lift off the lesions, but there was a non-lifting sign, and thus indicated the lesions likely submucosal in nature. A catheter probe EUS showed air shadowing and artifact (middle image). A needle knife was then used to incise the mucosa of the lesions, revealing an empty cavity without blood or fluid and thus “deflating” the lesion (bottom image). The patient tolerated the procedure well.
Discussion: This is a rare case of PCI that was diagnosed not with CT imaging, but with endoscopy. A normal appearing mucosa, a non-lifting sign, and most importantly, the air artifact on endoscopic ultrasound, were pivotal features found on endoscopy. PCI of the colon can present as submucosal lesions. Management is usually expectant as these are rarely malignant. In cases of large lesions endoscopic “deflation” can be performed.
Figure: Top: Submucosal lesion in the colon. Middle: EUS showing air shadowing and artifact. Bottom: A deflated lesion after needle knife incisional therapy.
Samuel Ji indicated no relevant financial relationships.
Peter Nguyen indicated no relevant financial relationships.
Nathan Park indicated no relevant financial relationships.
Rochelle Simoni indicated no relevant financial relationships.
Vamsi Vemireddy indicated no relevant financial relationships.
Jason Samarasena: Cook Medical – Grant/Research Support. Olympus – Consultant.
Samuel Ji, DO1, Peter H. Nguyen, MD1, Nathan Park, MD2, Rochelle Simoni, BSc3, Vamsi Vemireddy, MD4, Jason Samarasena, MD5. P2323 - It’s Anybody’s Gas: How Mysterious Colonic Lesions Were Diagnosed With Endoscopy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.