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Letter to the Editor
Rectal pneumatosis close to a colorectal
anastomosis unmasked by cystic spaces in a cold
snare resection defect
Vincent Zimmer
a,b,
*
To the Editor:
A 59-year-old male patient was referred by a collaborating
endoscopist for a second opinion concerning questionable
polypoid lesions in the rectum just below a colorectal
anastomosis with essentially normal mucosal biopsies. Of note,
history included subtotal colectomy due to colon cancer and
multiple advanced polyps in the setting of MYH-associated
polyposis (MAP). Recent colonoscopy revealed some subepi-
thelial lesions in the upper rectum with firm consistency on
forceps palpation (Fig. 1A). Meticulous endoscopic assessment
indicated smooth surface with normal mucosal and vessel
pattern. (Fig. 1B—not shown ancillary linked color imaging and
blue laser imaging characterization) To unequivocally clarify
the nature of the lesions, cold snare resection (or, in the case of a
truly solid subepithelial lesion, “decaptation”to allow for deep
biopsies) was performed without complications. Intriguingly,
visualization of the resection bed, apparently enough reaching
the submucosal space, demonstrated multiple intramural cystic
spaces (Fig. 1C), more clearly discernible on more close-up
views (Fig. 1D). By contrast, pathology assessment of the
mucosal biopsy specimen reaching beyond the muscularis
mucosae did not demonstrate typical histological findings in
pneumatosis, e.g., empty spaces implying pseudolipomatosis
with histiocytes/giant cells, which may be attributable to deeper
localization of pneumatosis cysts in this case.
While several endoscopic techniques unmasking pneumatosis
cysts, such as underwater biopsy, have been reported, as we are
aware, direct endoscopic visualization of such lesions in deeper
wall layers represents an altogether novel finding.
1
In the same
line, albeit potentially less reliable in the characterization of such
small lesions, endoscopic ultrasound and/or cross-sectional
imaging may have been discussed as ancillary diagnostic
modalities in this case; the most valuable, potential benefit of
Figure 1. (A) Lower endoscopy demonstrates several nodular-appearing lesions with smooth overlying mucosa just below the ileorectal anastomosis following
subtotal colectomy. (B) Detailed endoscopic view of the lesion targeted for cold snare resection. (C) Visualization of the cold snare resection defect with multiple
cystic lesions in the submucosal space, (D) which is further highlighted by close-up views.
a
Department of Medicine, Marienhausklinik St Josef Kohlhof, Neunkirchen,
Germany,
b
Department of Medicine II, Saarland University Medical Center, Saarland
University, Homburg, Germany
*Corresponding author: Department of Medicine, Saarland University Medical
Center, Kirrberger Strasse 100, 66421 Homburg, Germany. E-mail address: vincent.
zimmer@uks.eu (Vincent Zimmer).
Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of
PBJ-Associação Porto Biomedical/Porto Biomedical Society.
This is an open access article distributed under the terms of the Creative Commons
Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is
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journal.
Porto Biomed. J. (2023) 8:5(e227)
Received: 21 May 2023 / Accepted: 10 July 2023
http://dx.doi.org/10.1097/j.pbj.0000000000000227
1
the presented approach is in its “one-stop shop nature,”relying
on endoscopy only, allowing for a streamlined “real-time”
diagnosis of this rather uncommon, yet benign entity.
Reference
[1] Zimmer V, Puschel W. The “Bubble Sign”indicating ileal pneumatosis
cystoides. Clin Gastroenterol Hepatol. 2021;19:A17.
2
Zimmer Porto Biomed. J. (2023) 8:5 Porto Biomedical Journal