Clinical and imaging features indicative of clinically worrisome pneumatosis: key components to identifying proper medical intervention.

Purpose: The purpose of this retrospective study was to determine clinical and imaging factors on computed tomography (CT) associated with clinically worrisome pneumatosis intestinalis (PI) that may aid in the decision to provide conservative management or urgent surgical intervention.

Methods: Informed consent was waived in this IRB approved study. Imaging features assessed included the presence, location, and pattern of PI, bowel dilatation, thickening, enhancement, stranding, portal venous (PV) and mesenteric venous gas, mesenteric edema, free air, and ascites. Two radiologists retrospectively evaluated 167 patients with CT reports containing the text "PI" between 1/1/11 and 12/31/13. Clinical data collected included serum lactate, malignancy, bowel disease, operative findings, and death during admission. Clinically, worrisome PI was tabulated by summation of surgical diagnosis of dead bowel and/or death during admission. Chi-square test or Fisher's exact test was used when appropriate to compare subjects with benign or worrisome PI for categorical variables and the Mann-Whitney test used to compare continuous measures.

Results: Clinically, worrisome PI was present in 44 cases. Benign PI was diagnosed in 97 cases, and these patients were followed conservatively. There was a statistically significant association between clinically worrisome PI and imaging features: location in small bowel (p < 0.0001), bowel dilatation (p = 0.0003), stranding (p = 0.0002), bowel enhancement (p = 0.0384), PV gas (p < 0.0001), mesenteric venous gas (p = 0.0141), and moderate mesenteric edema (p = 0.0036). Location of PI in the small bowel exhibited a statistically significant association with benign PI (p < 0.0002). Statistical significance was found between worrisome PI and the following clinical features: elevated serum lactate (p = 0.0003), underlying bowel disease (p = 0.0004), and mechanical cause of bowel obstruction (p = 0.0497).

Conclusion: CT imaging characteristics and clinical features can help predict clinically worrisome PI and guide crucial management decisions.