Pneumatosis intestinalis in non-neonatal pediatric patients

Objectives. To describe fully pneumatosis intestinalis (PI) in non-neonatal pediatric patients and to characterize those patients with higher risk of poor outcome, including need for surgery and death. Methods. A retrospective chart review was conducted of all patients 30 days of age and older with PI in a tertiary care children's hospital during an 8-year period. Underlying medical condition, presenting signs and symptoms, radiologic grade of pneumatosis, and events that immediately preceded the onset of PI were reviewed, and their correlation with outcome was assessed. Results. Thirty-seven episodes of PI occurred in 32 patients. Seventy-eight percent of patients were male, and the median age was 29 months. Major patient diagnostic groups identified with PI included healthy children (22%), patients with organ and bone marrow transplant (22%), patients with decompensated congenital heart disease (12.5%), motility disorders (12.5%), gastroschisis (9%), and short bowel syndrome (6%). The most common events that immediately preceded the onset of PI were noninfectious colitis (32%), acute enteric infection or toxin (27%), bowel ischemia (20%), and gastrointestinal dysmotility (17%). Resolution of PI with medical management occurred in 78% of episodes (good outcome). Twenty-two percent of episodes resulted in a poor outcome: patient death (8%) or surgery (14%). The presence of portal venous gas and low mean serum bicarbonate concentration were the only clinical factors that correlated significantly with poor outcome. Only 25% of patients with pneumoperitoneum required surgery. Poor outcome was seen most commonly in 2 patient diagnostic groups: transplant patients (43% of patients) and decompensated cardiac disease (50% of patients). The event that preceded PI also had an impact on outcome. PI preceded by ischemia or graft versus host disease colitis was associated with poor outcome in 50% and 75% of cases, respectively. Conclusions. PI is a radiologic sign that occurs in a variety of settings in non-neonates. PI preceded by bowel ischemia or graft versus host disease colitis has the worst prognosis, and the presence of portal venous gas and acidosis correlate with poor outcome. Not all patients with pneumoperitoneum require surgical intervention. Overall, outcome of PI in non-neonatal patients was better than that reported in neonates with necrotizing enterocolitis.