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Objective:
Our purpose is to aid in differentiating diagnostic criteria for benign and life-threatening pneumatosis intestinalis (PI) as it is crucial in identifying appropriate management. We hypothesize benign PI within the adult population will be localized to the colon; while, PI within the small bowel will almost always be life-threatening. Additionally, we hypothesize associated Computed Tomography (CT) findings such as portal venous gas, mesenteric venous gas, pneumoperitoneum, and bowel wall thickening will not have a significant role in differentiation of benign or life-threatening PI.

Materials and Methods:
A retrospective PACS and electronic medical record review was performed of adult patients with radiologically documented PI in the stomach, small bowel, and large bowel from 1/1/2021- 12/31/2015. Collected data were deidentified and kept in a secure manner. Our study team includes two surgeons and three radiologists, who were blinded to the final pathological or surgical patient data. Radiologists collected data utilizing the patients’ CT findings while surgeons gathered the corresponding clinical data. Then, radiologists and surgeons separately determined the diagnosis as benign or life threatening PI. Finally, patients were grouped into life threatening or benign PI categories based on pathology, operating room findings and clinical outcomes.

Results:
Seventeen total gastric PI cases were assessed: 10 grouped into benign, 6 into life-threatening and 1 indeterminate. Radiologist and surgical diagnosis varied 7 times. Eight times (47%) both the surgeons and the radiologists categorized the patients correctly. One life-threatening case was incorrectly characterized by both surgeons and radiologists. Twenty-five small bowel cases were reviewed; 15 grouped as life threatening PI (60%). Eight of these cases demonstrated portal venous gas, while 11 demonstrated lactic acidosis. Radiologists and surgeons characterized these correctly 56% of the time. One life threatening case of PI was mischaracterized by both teams. Fifty-four large bowel cases were reviewed; of these 41 (76%) were benign PI. Seven (12%) were found to be life-threatening PI and 3 unknowns. Radiologists and surgeons characterized 45 (85%) cases correctly. Three of the benign cases demonstrated portal venous gas. Fourteen benign cases demonstrated pneumoperitoneum. Seven benign cases had elevated lactic acid.

Conclusion:
The distinction between benign and life-threatening PI is critical. Our study aims to categorize life threatening and benign PI in the stomach, small bowel and large bowel separately. Our study findings suggest that surgeons and radiologists vary in the diagnosis quite often. Radiologists are more likely to base their suspicion for life threatening PI on ancillary CT findings such as pneumoperitoneum and portal venous gas. Surgeons are more likely to base their suspicion for life threatening PI on clinical data such as lactic acidosis, and hypotension.