Pneumatosis intestinalis: Benign or dire? What you need to know

Pneumatosis intestinalis (PI) is defined as the presence of gas within the gastrointestinal wall and represents a radiologic finding with a broad clinical spectrum, ranging from incidental, benign disease to dire, life-threatening bowel ischemia. With the widespread availability of high-resolution computed tomography (CT), PI is increasingly identified in trauma and acute care settings, often prompting surgical consultation despite highly variable clinical significance. The current understanding is that PI is a multifactorial process arising from three nonmutually exclusive theories: mechanical, bacterial, and pulmonary, each rationalizing how gas can migrate and dissect into the intestinal wall. CT is the preferred diagnostic modality and provides critical features for risk stratification, including portomesenteric venous gas, decreased bowel wall enhancement, bowel dilation, and mesenteric fat stranding. Clinical presentations of peritonitis, hemodynamic instability, vasopressor requirement and laboratory evidence of elevated serum lactate (≥2.0 mmol/L), metabolic acidosis, or end-organ dysfunction are some of the strongest predictors of pathologic PI requiring surgical intervention. Management, therefore, requires a comprehensive examination of the patient with integration of imaging, clinical, and laboratory data to distinguish patients appropriate for conservative therapy from those requiring urgent/emergent exploration. This review encompasses current evidence on the pathophysiology, epidemiology, imaging characteristics, and management of PI with an emphasis on practical guidance. We also provided 10 concise clinical pearls to aid bedside decision-making. ( J Trauma Acute Care Surg . 2026;101: 187-198. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).