Pneumatosis intestinalis: Roentgen diagnosis and surgical management

The first American report of a roentgenologic preoperative diagnosis of pneumatosis intestinalis is presented. The characteristic roentgenographic features are described. The various etiologies of this entity are discussed and a theoretical concept of its development is presented. It is suggested that the process is as follows: A break develops in the mucous membrane of the bowel associated with some form of partial or complete obstruction of a part of the intestinal tract distal to this mucosal defect. The obstruction may occur from stenosis or adhesions. Because of the obstruction, hyperperistalsis take place and forces gas out of the lumen of the bowel into the wall where it comes to lie either in the subserosal or the mucosal layers. The presence of the gas causes obstruction of the lymphatics and associated inflammatory changes. Normally the gas is re-absorbed. If, however, the inflammatory and stenotic factions persist in the lymphatic system and become marked, absorption of the gas is blocked and the process become irreversible. The problem of conservative versus radical surgery in the treatment is raised. It is the opinion of the authors that the management of this entity demands a careful evaluation of the stage to which any given case has progressed. If the features of the case appear to be irreversible, radical surgery is indicated. In many cases simple relief of the obstruction may be sufficient. The case presented in this report is one in which conservative surgical management (lysis of adhesions) was tried at first, only to require the more radical procedure of extensive small bowel resection at a later date.