Surgical Intervention Not Always Needed for Pneumatosis Intestinalis

Pneumatosis intestinalis (PI), a potentially fatal occurrence, is often treated surgically, but new data from a retrospective study suggest many patients with PI are good candidates for nonoperative management. Investigators for the study, published in Archives of Surgery [2011;146(5):506-510], said findings of peritonitis and abdominal distention during a physical examination, dilated loops of bowel observed with computed tomography (CT) scanning, and lactic acidemia are significant indications that surgical intervention is warranted. Investigators reviewed records for 150 adults with PI confirmed via CT scanning who were admitted consecutively to a tertiary care hospital or affiliated community hospital. The objective was to identify clinical, laboratory, or radiographic results that could serve as independent predictors of the need for operative management. They analyzed the frequency with which an abnormal preoperative finding correlated with a positive intraoperative finding in surgically treated patients. Conversely, researchers also looked for associations between lack of a typical sign or symptom and successful nonoperative management. A total of 72 patients (48%) underwent surgery for PI. Another 54 patients (36%) received nonoperative management initially, although 3 later required surgery. Palliative care was administered to the 24 (16%) patients for whom treatment was considered futile, all of whom either died or were discharged to hospice, according to the study results. In the nonoperative group, 50 patients improved without surgical intervention and were discharged; 1 patient died of causes unrelated to PI. In the surgical group, intraoperative findings were positive for 63 (87%) patients and negative for 9 (13%); 21 patients (28%) in this group died. The study’s mortality rate was lower than the historical mortality rate of 65% to 86% and in line with the 22% to 44% mortality rate observed in more recent studies, the researchers said. PI occurs when gas infiltrates the intestinal wall and is typically diagnosed during a physical examination or by radiograph. PI was previously considered a sign of bowel wall ischemia or necrosis and warranted immediate surgical intervention. A concomitant finding of portal venous gas (PVG) was believed to indicate mesenteric ischemia and a poor prognosis. Of the 41 study patients with PVG, 8 (28%) were successfully managed nonoperatively or underwent surgery but were found not to have mesenteric ischemia. A multivariate analysis found 3 parameters that are statistically significant predictors of the need for surgical intervention: abdominal distention observed during physical examination plus dilated loops of bowel on CT scanning (odds ratio [OR] for positive operative findings, 13.19; 95% confidence interval [CI], 2.81-61.93; P=.001); lactic acidemia, reflective of mesenteric ischemia (OR, 2.29; 95% CI, 1.17-4.51; P=.02); and peritonitis (OR, 9.35; 95% CI, 1.85-47.14; P=.007). All 3 findings were significantly less common among the nonoperative patients. The study was limited by the investigators’ inability to confirm whether patients considered futile (who were excluded from the analyses) had ischemia or other intra-abdominal pathology, which may have biased findings toward nonoperative management. Nor could they definitively determine the underlying cause of PI in the nonoperative group or whether they had ischemia at some point. Some operative patients had minor pathology that might have resolved without surgical intervention.