Resource utilization and surgical risk in pediatric pneumatosis intestinalis

Pneumatosis intestinalis (PI) in children, excluding necrotizing enterocolitis (NEC), is typically managed non-operatively with bowel rest, antibiotics, and total parenteral nutrition (TPN). However, guidance is limited on estimating the risk of requiring surgery, complicating decisions about the duration of non-operative medical treatment. This study aimed to assess the management of non-NEC PI and identify factors associated with surgical intervention.

A retrospective review was conducted of patients aged 6 months to 21 years diagnosed with PI from 2010 to 2023 at a free-standing children's hospital. Patients with NEC in the prior six months or abdominal surgery in the preceding three months were excluded.

102 patients (139 encounters) met inclusion criteria. Median age was 4.5 years; 29 % had genetic disorders, 22 % malignancies (17 on active treatment), and 13 % congenital heart disease. PI was identified via plain radiograph (71 %), CT (25 %), or both (4 %). In 16.5 % of cases, PI was an incidental finding. Antibiotics were used in 91 % of encounters and gastric decompression in 83 %. Surgery was required in 5 patients (3.6 %) due to radiologic progression (100 %), worsening pain/distention (100 %), fevers (60 %), and tachycardia (60 %). All surgical cases involved colonic PI and complex comorbidities. Four patients underwent bowel resection; two had colonic necrosis, and two had resections for underlying motility disorders.

Surgery for non-NEC pediatric PI was rare and associated with colonic involvement, fever, tachycardia, and comorbidities. Most cases resolved with a brief course of medical management. Identifying high-risk features may help reduce unnecessary treatment in low-risk patients.

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