The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review

TL;DR

This paper reviews the management of pneumatosis intestinalis, a condition with unclear causes, and suggests a cautious approach to surgery based on patient stability and signs of bowel damage.

Contribution

The study provides a systematic review of pneumatosis intestinalis management and identifies factors guiding surgical versus conservative treatment.

Findings

Hemodynamic instability is linked to bowel ischemia, necrosis, or perforation in patients with pneumatosis intestinalis.

Conservative management was used in nearly half of the cases, while surgery was reserved for unstable patients with signs of bowel damage.

Surgery performed without pathological findings highlights the challenge in diagnosing pneumatosis intestinalis.

Abstract

Purpose: Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention. Methods: A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items “emergency surgery, pneumatosis coli, and pneumatosis intestinalis” from January 2010 up to March 2022. This study has not been registered in relevant databases. Results: A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673–14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings. Conclusions: Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation.

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