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images in clinical medicine T h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 361;8 nejm.org august 20, 2009 e12 A 25-year-old woman presented with recurrent abdominal pain that had first developed 10 years earlier. Physical examination revealed mild tenderness in the left upper quadrant, without rebound or guarding. Laboratory tests showed no significant abnormalities. Coronal computed tomography (CT) (Panel A) and colonoscopy (Panel B, transverse colon) showed submucosal cysts confined to the splenic flexture and the distal transverse colon (arrows in Panels A and B), which were consistent with pneumatosis cystoides coli. One year before presentation, acute pain had developed in the left upper quadrant as a result of microperforation. At that time, CT revealed a small amount of air outside the colon and associated inflammation. The patient was treated nonoperatively, with good results. Given her persistent localized symptoms and the involvement of a discrete segment of her colon, laparoscopic resection of the transverse colon and splenic flexure was performed, without complications, and the patient has been asymptom-atic since the surgery. The pathological specimen showed the characteristic features of pneumatosis cystoides coli, air-filled cysts of various sizes in the submucosa and subserosa of the colon (Panel C, arrows). Pneumatosis cystoides coli can be focal or diffuse and occurs mainly in adults. It is usually asymptomatic but can cause obstruction or pneumoperitoneum as well as intermittent or persistent pain.