Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis

Abstract

Objective: Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients.

Methods: The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management.

Results: Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm.

Conclusions: The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.

Figure 1

Intraoperative causes of pneumatosis intestinals related to the large bowel. Toxic megacolon coursed by Clostridium difficile infection (A), Necrosis of the colon (colon transversum) with gangrenous bowel wall by mesenterial embolism (B and E), severe bleeding caused by ulcerative colitis (C and D), necrotic appendicitis (F and G).

Figure 2

Intraoperative causes of pneumatosis intestinalis related to the small bowel. Limited early small bowel ischemia (A), extended hemorrhagic small bowel infarction (B), small bowel ischemia with partial necrosis (C), gangrenous ileum segment small bowel caused by ischemia (D), necrotic ileum segment (E) due to a bridle stricture (F), ischemic ileum segment (G) and detailed view of G showing a constriction mark as its cause (H).

Figure 3

Clinical pictures of the abdomen in patients with diagnosis of pneumatosis intestinalis and operative findings. Volvulus of the colon sigmoideum (A and B), blunt abdominal trauma (C and D), and toxic mega-colon (E and F).

Figure 4

Representativ computed tomographic findings of pneumatosis intestinalis (A and C), B is a magnifiation of A and D a magnification of C. Examples of portal venous gas leading to intrahepatic gas formation (E and F). The white arrows indicates the gas bubbles.

Figure 5

Decision making algorithm after diagnosis of pneumatosis intestinalis. CT (computed tomography), PC (physical condition), PE (physical examination), PMH (past medical history). *In some cases reevaluation can be done by ultrasound instead of CT scan.