Non-enhancing bowel dilatation and secondary ileus on CT as a surgical red flag in geriatric patients with atypical presentations.

Background: Ischemic bowel disease represents a critical diagnostic challenge in emergency surgical practice. Despite its relatively low incidence in patients presenting with abdominal pain, this condition demands urgent attention due to its potentially fatal outcomes when management is delayed.

Case presentation: We present a clinically instructive case of a nonagenarian female initially diagnosed with colonic pneumatosis through imaging studies. Subsequent diagnostic reevaluation revealed progressive colonic necrosis requiring emergent surgical intervention. The patient underwent successful segmental colectomy with colostomy, achieving full recovery and discharge within 14 postoperative days.

Conclusion: This case highlights three critical aspects in managing geriatric patients with acute abdominal emergencies: The inherent diagnostic limitations posed by atypical presentations in elderly populations, including unreliable history-taking and attenuated physical signs; The insufficient sensitivity of conventional laboratory markers (leukocytosis, NEUT%, PCT, lactate elevation) for detecting intestinal ischemia; The pivotal role of contrast-enhanced computed tomography (CT) in surgical decision-making, particularly the prognostic significance of non-enhancing bowel wall dilatation as a radiographic hallmark of transmural necrosis. Early surgical consultation and protocolized CT interpretation are paramount for optimizing outcomes in this high-risk patient cohort.