Pneumatosis Intestinalis (PI) is an uncommon condition in which there is gas present within the wall of the gastrointestinal tract. PI is usually found in the large bowel, but can less commonly occur in the small bowel, and gas may be present in either the subserosal or submucosal layer of the intestine. Its unfamiliarity often means it is under-recognised and not considered as a differential diagnosis when assessing a patient with abdominal symptoms.The spectrum of conditions that produce PI is varied and ranges from the non-urgent to life-threatening. Early appreciation of the overall clinical picture is therefore paramount to enable the practitioner to distinguish between the benign to the fatal cases of PI and enable precise decision-making regarding its management.The challenge facing the clinician is twofold; firstly the accurate identification of the diagnosis of PI, as opposed to other causes of peritoneal gas and secondly judging whether operative or non-operative management should ensue. We present a case of a patient presenting on two separate occasions with PI, abdominal symptoms and radiological signs of acute abdominal pathology which demonstrates the wide spectrum of difficulties faced with this uncommon condition.

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