Abstract
Pneumatosis intestinalis (PI) is the presence of air within the bowel wall and may represent a benign finding of no clinical significance or more serious bowel ischemia. Given the broad spectrum of causes of PI, diagnosis and treatment can be difficult. Clinical scenario, physical examination, radiographic, and laboratory findings all need to be assessed to determine when exploration is necessary. Clinical signs and symptoms necessitating operative intervention are diffuse peritonitis, shock, leukocytosis, and lactic acidosis. Radiographic signs suggesting the presence of ischemia are bowel dilation, mesenteric stranding, and ascites. Once the decision is made to operate, clearly ischemic bowel should be resected, while areas of questionable ischemia can be assessed with Doppler signal, palpation of a mesenteric pulse, and fluorescein evaluation. Rather than overly aggressive resection of marginally viable bowel, the abdomen should be temporarily closed with a planned second-look laparotomy in 24–48 h. When the etiology of PI is the result of a thrombus or embolus, either vascular bypass or embolectomy will need to be performed to minimize the extent of gangrene and need for further resection. In the setting of venous outflow obstruction, anticoagulation must be used expeditiously. Complications of PI associated with bowel ischemia include short bowel syndrome, fistula formation, and prolonged open abdomen with subsequent incisional hernia development.
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Suggested Reading List
DuBose JJ, Lissauer M, Maung AA, Piper GL, O’Callaghan TA, et al. Pneumatosis intestinalis predictive evaluation study (PIPES): a multicenter epidemiologic study of the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2013;75:15–23.
Duron VP, Rutigliano S, Machan JT, Dupuy DE, Mazzaglia PJ. Computed tomographic diagnosis of pneumatosis intestinalis. Arch Surg. 2011;146(5):506–10.
Greenstein AJ, Nguyen SQ, Berlin A, Corona J, Lee J, et al. Pneumatosis intestinalis in adults: management, surgical indications, and risk factors for mortality. J Gastrointest Surg. 2007;11:1268–74.
Lee H, Cho Y, Kim K, Lee JS, Lee SS, et al. A simple score for predicting mortality in patients with pneumatosis intestinalis. Eur J Radiol. 2014;83:639–45.
Wayne E, Ough M, Wu A, Liao J, Andresen KJ, Kuehn D, et al. Management algorithm for pneumatosis intestinalis and portal venous gas: treatment and outcome of 88 consecutive cases. J Gastrointest Surg. 2010;14:437–48.
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Lasinski, A.M., Posluszny, J., Luchette, F.A. (2017). Small Bowel: Pneumatosis Intestinalis. In: Diaz, J., Efron, D. (eds) Complications in Acute Care Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-42376-0_13
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DOI: https://doi.org/10.1007/978-3-319-42376-0_13
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