Teasing out factors differentiating pathologic from benign pneumatosis intestinalis.

Background: Pneumatosis intestinalis (PI) is a rare radiographic finding that can range from being a benign process to needing emergency surgery. Sufficiently powered studies are lacking, and recommendations for management remain unclear. The purpose of this study was to identify key predictors of pathologic PI using physical examination, laboratory, and radiographic findings.

Methods: A retrospective cohort study was conducted at two quaternary academic centers (2010-2020). A total of 334 consecutive patients 18 years or older with radiographic evidence of PI were identified. Patients were excluded if they pursued comfort care or if there was concurrent radiographic evidence of vaso-occlusive process. Pathologic PI was defined as presence of ischemic and/or perforated bowel on exploratory laparotomy or death prior to planned surgery.

Results: Of the 334 patients included in our study, 91 (27%) underwent exploratory laparotomy, of which 59 (65%) had ischemic and/or perforated bowel. These latter patients and 10 other patients who died before exploratory laparotomy defined the pathologic PI cohort. A stepwise model was created for predicting pathologic disease. Significant predictors were the presence of portal venous gas, multisegment PI, vasopressor use, peritonitis, increasing leukocyte count, and end organ injury, which were used to construct a nomogram for clinical use.

Conclusion: A nomogram score based on presence of portal venous gas, multisegment PI, vasopressor use, peritonitis, leukocytosis, and end organ injury may help predict the probability of pathologic PI and therefore can inform surgical decision making.

Level of evidence: Therapeutic/Care Management; Level III.