A rare cause of lower gastrointestinal bleeding: Pneumatosis cystoides intestinalis

A 70-year-old man presented to the emergency department with 1-week history of rectal bleeding. Physical examination was unremarkable. Laboratory tests revealed no abnormalities. Colonoscopy revealed multiple submucosal cysts of varied sizes in the descending colon, some with markedly erythematous overlying mucosa (Fig. 1); one of the cysts was biopsied, with release of gas and subsequent cyst deflation. Abdominal computerized tomography (CT) confirmed the presence of multiple grape-like air collections within the bowel wall of the descending colon (Fig. 2), confirming the diagnosis of pneumatosis cystoides intestinalis (PCI). The patient was managed conservatively and discharged 2 days later, without further gastrointestinal (GI) bleeding. Unfortunately, he was lost to follow-up.

Figure 1.

Colonoscopy with multiple cystic images of varied sizes in the descending colon (A), with erythematous overlying mucosa (B).

Figure 2.

Abdominal CT images showing air-filled cysts within the bowel wall (arrows) of the descending colon.

PCI is a rare disease characterized by accumulation of cysts filled with gas in the intestinal wall. Clinical manifestations are nonspecific, including abdominal pain, bloating, diarrhea or lower GI bleeding. Endoscopically is characterized by multiple protuberant lesions covered by normal or erythematous mucosa; as such findings are suspicious but not diagnostic, usually abdominal CT is required for confirmation, showing gas-filled clusters in the bowel wall.¹ There is no consensus regarding treatment; however, conservative management is successful in most cases.²