From the Guidelines
Pneumatosis intestinalis is a condition that can range from benign to life-threatening, and its management depends on the underlying cause and severity, with conservative management or immediate surgical intervention being necessary based on the presence of intestinal ischemia, sepsis, or perforation. The causes of pneumatosis intestinalis are diverse and include:
- Mechanical factors (such as intestinal obstruction, trauma, or surgery)
- Inflammatory conditions (like inflammatory bowel disease or necrotizing enterocolitis)
- Infectious processes
- Immunosuppression
- Pulmonary diseases
- Medication effects (particularly from steroids, chemotherapy, or immunosuppressants) 1. According to a recent study, six radiological findings (bowel loop dilatation, pneumatosis intestinalis, SMV thrombosis, free intraperitoneal fluid, portal vein thrombosis, and splenic vein thrombosis) were found to be predictors of bowel necrosis in patients with acute mesenteric ischemia (AMI) 1. For benign or incidental pneumatosis, conservative management with close observation, bowel rest, and antibiotics like metronidazole 500mg three times daily for 7-10 days may be sufficient, as well as oxygen therapy at 70% concentration for 5 days to help eliminate the intestinal gas by creating a diffusion gradient. However, for severe cases with signs of intestinal ischemia, sepsis, or perforation, immediate surgical intervention is necessary, typically involving exploratory laparotomy with resection of necrotic bowel segments. The key to effective management is determining whether the pneumatosis represents a benign finding or indicates a life-threatening condition requiring urgent intervention, which should include evaluation of clinical symptoms, laboratory findings (particularly lactate levels and white blood cell count), and imaging studies to guide appropriate treatment decisions 1.
From the Research
Causes of Pneumatosis Intestinalis
- Pneumatosis intestinalis (PI) is a condition characterized by the presence of gas within the bowel wall, and it can be caused by various factors, including cytotoxic or immunosuppressive treatment for hematological disorders 2.
- It can also be associated with inflammatory bowel diseases, malignancies, chemotherapy, infections, immune deficiency status, trauma, intestinal ischemia, and necrosis 3.
- Additionally, PI can occur after hematopoietic stem cell transplantation, particularly in patients with myelodysplastic syndrome 4.
- Other causes of PI include gastrointestinal, pulmonary, autoimmune, and other diseases, making it challenging to differentiate the etiology and clinical importance of the radiographic evidence 5.
- In some cases, PI can be secondary to hypermobile mesentery, which can cause segmental small bowel pneumatosis cystoides intestinalis 6.
Management of Pneumatosis Intestinalis
- Conservative treatment with broad-spectrum antibiotics and parenteral nutrition can be effective in managing PI, especially in the absence of secondary complications such as peritonitis, ischemia, or perforation 2.
- In cases where PI is severe or accompanied by bowel ischemia, portomesenteric venous gas, metabolic acidosis, and abdominal sepsis, immediate surgical intervention may be indicated 4.
- The presence of portal venous gas can pose a question of whether surgical intervention is needed, and further research is necessary to standardize a plan of care, including indications for surgery 5.
- In some cases, surgical intervention may be required, such as in cases of segmental small bowel PCI secondary to hypermobile mesentery, where exploratory laparotomy and resection of the affected segment may be necessary 6.