The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review

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.

Intestinal Emphysema and Gut Bacterial Microbiota Composition

“…This procedure reproduced intestinal emphysema lesions, endorsing the theory that increased permeability of the mucosa may generate the characteristic lesions [43]. According to a recent review, the secondary causes in humans can be linked to various conditions involving the gut, but in many cases, the etiology is unknown [12].…”

“…According to this theory, the bacteria would reach serosa due to increased mucosal permeability [11]. The incidence of intestinal emphysema is unknown in humans, although the increasing use of CT may help fill this gap [12]. Limited data are available on pigs, and little focus has been placed on the topic.…”