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World J Gastrointest Surg. Apr 27, 2023; 15(4): 553-565
Published online Apr 27, 2023. doi: 10.4240/wjgs.v15.i4.553
The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma
Giuseppe Tropeano, Marta Di Grezia, Caterina Puccioni, Valentina Bianchi, Gilda Pepe, Valeria Fico, Gaia Altieri, Giuseppe Brisinda
Giuseppe Tropeano, Marta Di Grezia, Caterina Puccioni, Valentina Bianchi, Gilda Pepe, Valeria Fico, Gaia Altieri, Giuseppe Brisinda, Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
Giuseppe Brisinda, Department of Surgery, Università Cattolica del Sacro Cuore, Rome 00168, Italy
Author contributions: Tropeano G and Di Grezia M equally contributed to the drafting of the manuscript and must both be considered first author; Tropeano G, Di Grezia M, Puccioni C, Bianchi V and Brisinda G designed the research; Bianchi V, Pepe G, Fico V and Altieri G performed the research and selected the articles; Tropeano G, Di Grezia M and Puccioni C analyzed the data; Tropeano G, Di Grezia M, Puccioni C and Brisinda G reviewed the selected manuscripts and wrote the paper; All the authors read and approved the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Giuseppe Brisinda, MD, Professor, Surgeon, Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Largo Agostino Gemelli 8, Rome 00168, Rome, Italy. gbrisin@tin.it
Received: December 7, 2022
Peer-review started: December 7, 2022
First decision: February 8, 2023
Revised: February 10, 2023
Accepted: March 21, 2023
Article in press: March 21, 2023
Published online: April 27, 2023
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.

Keywords: Pneumatosis intestinalis, Risk factors, Treatment, Portal venous gas, Portomesenteric pneumatosis

Core Tip: Pneumatosis intestinalis (PI) represents a radiological diagnosis that must be understood correctly in order to follow the appropriate management. It is essential to identify the conditions that can evolve into transmural intestinal ischemia. It is also important to recognize those cases where PI can be managed conservatively. The integration of the clinical presentation, laboratory tests and abnormal abdominal physical examination can give indications on the path to follow. With this narrative review we have tried to provide a comprehensive analysis of the knowledge of this topic by proposing an algorithm to guide clinical decisions.