Management Algorithm for Pneumatosis Intestinalis and Portal Venous Gas: Treatment and Outcome of 88 Consecutive Cases

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. 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. 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%. 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.