Management algorithm for pneumatosis intestinalis and portal venous gas: Treatment and outcome of 88 consecutive cases

Abstract

Background: Pneumatosis intestinalis (PI) and portal venous gas (PVG) historically mandated laparotomy due to the high mortality rate associated with mesenteric ischemia. Computed tomography (CT) can identify PI/PVG in patients with ischemic emergencies and benign idiopathic conditions. Methods: A consecutive series of patients with PI or PVG was reviewed from a single institution over 5 years. Eighty-eight cases of PI/PVG were studied: 74 initial patients (year 1-4) were used to generate a treatment algorithm and fourteen additional cases were used to test the algorithm. Results: PI and PVG were associated with three major clinical subgroups: mechanical causes (n = 29), acute mesenteric ischemia (n = 29), and benign idiopathic (n = 26); four were unclassifiable. Patients with acute mesenteric ischemia were associated with abdominal pain (p = 0. 01), elevated lactate (≥3. 0 mg/dL; p = 0. 006), small bowel PI (p = 0. 04), and calculated vascular disease score (p < 0. 0005). The three subgroups could be distinguished using the generated algorithm with a sensitivity of 89%, specificity of 100%, and positive predictive value of 100%. Conclusions: With greater sensitivity of modern CT scans, PI and PVG are being detected in patients with a wide range of surgical and non-surgical conditions. This clinical algorithm can identify subgroups to direct surgical intervention for acute ischemic insults and prevent non-therapeutic laparotomies for benign idiopathic PI and PVG. © 2010 The Society for Surgery of the Alimentary Tract.