The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma

Abstract

Pneumatosis intestinalis (PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition. Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging, even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated. Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier, identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.

Chemotherapy-induced pneumatosis intestinalis followed by hepatic portal venous gas. A case report

“…2 However, its clinical presentation may vary from asymptomatic to critical illness. 3 Symptomatic patients may present with abdominal pain, weight loss, constipation or diarrhoea but more alarming clinical features such as bowel obstruction, bowel ischemia, pneumoperitoneum or peritonitis, with or without hemodynamic instability can also occur. 3 Diagnosis is typically radiological, and a CT scan is the gold standard for establishing the presence of PI.…”

Pneumatosis Intestinalis Concurrent with Superior Mesenteric Artery Thrombosis: A Case Report

“…It is most commonly seen in infants. Secondary Pneumatosis intestinalis is generally associated with a medical condition and is seen in adults [11]. It is more serious and presents with symptoms like fever, colicky pain, nausea, vomiting, and obstipation.…”

Intestinal pneumatosis: a problem of misdiagnosis

“…18 Tropeano et al (18) (2023) Italia Revisión El espectro de la neumatosis intestinal en el adulto. Un dilema quirúrgico.…”

“…(17,7) El diagnóstico de IP, generalmente proviene de una radiografía abdominal de manera incidental encontrándose bolsas de gas radiotransparentes, en forma de racimos de uvas o con forma de panal, a lo largo de la pared del intestino. (18) En pacientes seleccionados, la adición de una tomografía computarizada abdominal (modalidad de imagen más sensible para el diagnóstico) puede permitir la identificación de signos adicionales que reflejen la gravedad de la patología y determinar la etiología subyacente o identificar complicaciones que pueden alterar el curso de la terapia, como el engrosamiento de la pared intestinal, otra acumulación de gas, pared intestinal patológica o realce de contraste de tejidos blandos, dilatación de la luz intestinal, líquido en la cavidad peritoneal y gas en la vena porta; sin embargo, los hallazgos de la TC no son patognomónicos de Presión Intra Craneal (PIC). (19,8) El diagnóstico diferencial incluye condiciones potencialmente mortales, tales como: isquemia intestinal, infarto, enterocolitis necrotizante, colitis neutropénica, megacolon tóxico, obstrucción o estrangulación intestinal, traumatismo y sepsis.…”

“…La presencia de signos ominosos, síntomas de peritonitis y anomalías de laboratorio, así como un recuento elevado de glóbulos blancos y acidosis, deben generar preocupación sobre estas enfermedades. (18,4)…”