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

J Gastrointest Surg. 2010 Mar;14(3):437-48. doi: 10.1007/s11605-009-1143-9.


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 (>or=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.

MeSH terms

  • Abdominal Pain / diagnosis
  • Abdominal Pain / etiology
  • Adult
  • Aged
  • Aged, 80 and over
  • Algorithms*
  • Cohort Studies
  • Female
  • Gases
  • Humans
  • Ischemia / diagnostic imaging*
  • Ischemia / surgery
  • Laparoscopy
  • Laparotomy / methods
  • Male
  • Mesentery / blood supply*
  • Middle Aged
  • Pneumatosis Cystoides Intestinalis / complications
  • Pneumatosis Cystoides Intestinalis / diagnostic imaging*
  • Pneumatosis Cystoides Intestinalis / mortality
  • Pneumatosis Cystoides Intestinalis / surgery*
  • Portal Vein / diagnostic imaging*
  • Retrospective Studies
  • Risk Assessment
  • Severity of Illness Index
  • Survival Rate
  • Tomography, X-Ray Computed
  • Treatment Outcome


  • Gases