The radiologist's dilemma: Differentiating non-ischemic pneumatosis intestinalis from ischemic bowel necrosis

Pneumatosis intestinalis (PI) is defined by gas accumulation within the gastrointestinal wall and is frequently perceived as an indication of life-threatening bowel ischemia necessitating surgical intervention. However, PI can manifest as a benign entity, generating a significant diagnostic challenge between surgical and conservative management strategies. A 78-year-old male with chronic obstructive pulmonary disease (COPD) presented with mild abdominal pain and extensive small bowel intramural gas identified on computed tomography (CT), devoid of hemodynamic instability or lactic acidosis. Conservative management through bowel rest yielded substantial resolution of the intramural gas, successfully precluding surgery. While linear gas configurations frequently correlate with bowel ischemia, cystic morphologies - when assessed in conjunction with preserved bowel wall enhancement, absence of portal venous gas, and a stable clinical examination - should guide clinicians toward suspecting non-ischemic PI. Integrating CT imaging findings with clinical and biochemical parameters remains essential to circumventing unnecessary surgical exploration in non-ischemic presentations.