Pneumoperitoneum in the Setting of Pneumatosis Intestinalis in Children: Is Surgery Always Indicated?

Abstract

Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled cysts form within the wall of the gastrointestinal tract in either the subserosa or submucosa. The presence of pneumoperitoneum in the presence of PI can present a therapeutic dilemma. The aim of our study was to review our experience and management of this condition. A single-center retrospective study of consecutive children (> 1 year) presenting with a pneumoperitoneum and evidence of PI (2009-2015). Demographics, case notes, microbiology, and imaging were reviewed. Seven patients were identified (four males; age range 5-14 years). Four children had global developmental delay and were percutaneous endoscopic gastrostomy or jejunostomy fed, one was immunocompromised (acute lymphoblastic leukemia). The others had encephalitis and eosinophilic gastroenteritis. One patient proceeded to an exploratory laparotomy; no perforation was identified, pneumatosis of the colon was observed, and a loop ileostomy was formed. The remaining six were managed conservatively and made nil by mouth with intravenous antibiotics commenced. Five of the six had a computed tomography (CT) scan which revealed PI and free air with no other worrying signs. One died from nongastrointestinal causes, while the remaining five had feeds reintroduced uneventfully. Free air in the setting of PI may represent rupture of the gas cysts and not always transmural perforation. Surgery may not always be indicated and conservative management may suffice. A CT scan can be useful for excluding other intra-abdominal pathological findings and continued clinical assessment is essential.

Clinical Predictors and Outcomes for Recurrent Pneumatosis Intestinalis in Children: A Case Control Study

“…In the setting of pneumatosis, the extent of mesenteric ischemia has been associated with poor outcomes including surgery and death in addition to pneumoperitoneum and/or portal venous gas (3,5,10,21,25,26); however, both pediatric and adult cases of pneumoperitoneum have been managed conservatively when patients are clinically stable suggesting some finding may represent ruptured cystic structures rather than transmural bowel wall perforation (12,(27)(28)(29)(30). In this study, conservative management was pursued in >50% of cases in the setting of pneumoperitoneum (11/ 16 episodes) and portal venous gas (3/6 episodes).…”

Pneumatosis intestinalis in a cohort of children with neurological impairment: A patient group with a management dilemma

“…Galea et al . suggested that the use of computed tomography (CT) scan is a very useful tool for evaluation of these patients as PI has been reported to be missed on plain abdominal X‐rays in 23% of patients in one study . However, Correlation could not be established between CT scan findings and severity of bowel ischaemia, which makes its value questionable except if other abdominal pathologies are suspected.…”

“…Galea et al . recently published a group of seven patients, four of whom had global developmental delay and were similarly tube fed who had a presentation with pneumoperitoneum and were successfully managed conservatively …”

Detection of Intestinal Pneumatosis Location by Following Hyperechoic Foci in the Portal Vein Along Its Branches With Real‐time Ultrasound

“…Intestinal pneumatosis and portal venous gas are important findings suggestive of intestinal disorders . The location of intestinal pneumatosis contributes to prognoses in these cases .…”

“…I ntestinal pneumatosis and portal venous gas are important findings suggestive of intestinal disorders. [1][2][3][4][5][6][7][8][9][10][11] The location of intestinal pneumatosis contributes to prognoses in these cases. 1,3,5,6,9,[12][13][14][15][16] Previous reports have evaluated the location of pneumatosis using abdominal computed tomography (CT).…”