Nellihela L, et al. Management of pneumatosis intestinalis in children over the age of 6 months: a conservative approach. Arch Dis Child. 2017 Oct 7.
“Once PI is diagnosed, clinical correlation is essential in order to select the right treatment option. In cases of benign PI, pneumatosis is transient and the gas gradually migrates out of the gut wall resolving with conservative management. Incidental PI in asymptomatic individuals does not require active intervention and is likely to resolve spontaneously.  Symptomatic PI requires careful clinical and laboratory assessment to identify patients with ‘red flag’ features who may benefit from early surgical intervention. Studies in adult patients have suggested that high serum lactate, hypotension, peritonitis and acute renal failure are high-risk features requiring immediate surgical exploration. [7 25 26] None of our patients had any of those red flag signs and to the best of our knowledge, there is no such stratification algorithm for children with PI.
The conservative management of PI consists of bowel rest and decompression, antibiotics and management of underlying disease.  Some authors advocate the use of hyperbaric oxygen therapy for the management of symptomatic PI to decrease the partial pressure of non-oxygen gases in the venous system and enhance gas diffusion out of the bowel wall. [9 28] Oxygen can also act as a toxin to anaerobic bacteria in the GI tract. We did not use hyperbaric oxygen therapy in any of our patients as it is not part of local protocol.
In our cohort, despite the heterogeneity of medical conditions, all 18 children were managed conservatively with excellent outcome. We conclude that children with PI follow a more benign disease course and conservative medical therapy should be the first line of treatment. Surgical intervention should be deployed in acute cases, with suspected bowel necrosis or perforation.”
Yang T, et al. Pneumatosis intestinalis. Arch Dis Child. 2017 Jan;102(1):4.
Pneumatosis intestinalis is a condition in which multiple air-filled cysts develop in the intestinal submucosa or subserosa.1 There are several theories regarding the pathogenesis, involving mucosal integrity compromise, raised intraluminal pressure, bacterial flora and intraluminal gas interacting in the formation of pneumatosis intestinalis. In the vast majority of cases, pneumatosis develops secondary to a disruption of the mucosal integrity, often with an associated raised intraluminal pressure and translocation of bacteria into the bowel wall.2 Pneumatosis may be detected using plain abdominal radiography, ultrasound or CT. Abdominal radiography is diagnostic in approximately two-thirds of patients, while CT has greater sensitivity than radiography and ultrasonography.3 While sometimes a benign radiographic feature, pneumatosis intestinalis can be life-threatening if caused by bowel necrosis due to necrotising enterocolitis, neutropenic colitis, volvulus and sepsis, but severity can vary. Many cases can be managed conservatively.4 Considering the wide differential, paediatricians and paediatric surgeons may initially manage conservatively unless specific indications for surgery supervene.
George S, Cook JV. Pneumatosis intestinalis. J Pediatr. 2014 Sep;165(3):637.
“Pneumatosis, however, can be a more ominous finding in necrotizing enterocolitis or ischemic enteritis, where intramural gas forms as a result of bowel wall necrosis. In such cases, gas collections typically are linear and can be transmural. Other important radiographic findings in such scenarios may include pneumoperitoneum and portal venous gas. Computed tomography imaging may help to point towards an ischemic etiology by demonstrating additional features such as bowel wall thickening and abnormal enhancement patterns. In these situations, the onus is on prompt diagnosis and surgical assessment.
Ultimately, benign and serious pneumatosis can be difficult to differentiate by plain radiographs alone, and therefore consideration of the clinical context is essential.”
Kurbegov AC, Sondheimer JM. Pneumatosis intestinalis in non-neonatal pediatric patients. Pediatrics. 2001 Aug;108(2):402-6.
“This study indicates that there are few absolute indications for surgery in the non-neonate with PI and that experienced clinical judgment remains an important factor in directing management. Our results suggest that portal venous gas and acidosis are significantly associated with a need for surgery. The number of abdominal quadrants that showed pneumatosis did not correlate with outcome. Patients who were most likely to have a poor outcome were those with the underlying diagnoses of CHD or tissue transplant. The preceding events most commonly associated with a poor outcome were GVHD colitis and ischemia. It may be significant that these preceding events very closely resemble the situation in the neonate with NEC, ie, they produce a deep inflammatory and ischemic bowel wall injury that permits air dissection and a high risk of perforation.”