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Pneumatosis intestinalis - what’s your diagnostic approach and management?

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I would like to hear about how you diagnose and manage pneumatosis intestinalis.

the background - we sometimes comes across infants (mostly preterms) with some GI symtoms, like blood in stools, but without clinical signs and no lab signs towards NEC. But the xray shows some intramural gas.

we usually start conservative NEC TX (fasting, antibiotics, TPN) but stop it after a few days of normal blood tests and if xray normalize.

there are some Pubmed reports on this seemingly more benign phenomen but would be great to hear how you handle this.

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Stefan you have raised a very important finding and its management. We do face this problem. A lot of time this is also due to retained meconium which mimics like pneumatosis and if the baby is fine continuing the feeds is important. So it is important to differentiate the two. IF there are other radiological features suggestive of NEC and pneumatosis like dialted bowel loops, bowel wall thickening and clinical features we also do take conservative approach and also involve the pediatric surgeon right away so that he is aware incase the worsening happens and the kid needs surgery at any point. It is also a good idea to look at the electrolytes and blood gas and cbc to look at hidden deterioration.

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We have had the same issue a couple of times. I think the clinical condition of these babies are much better.

Despite this, we felt we could not ignore intestinal pneumatosis, but after a few days we started to carefully feed them after seeing IP resolution on USS, besides good clinical condition and negative infection markers.

I found this very old article (1974!) and made me think about “CPAP belly”/ distension...


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We had a similar issue a number of times. I personally came across children who seemed fine in terms of abdominal symptoms (no distension, good feeding tolerance) but presented with pneumatosis. In cases of massive pneumatosis we would usually start them on NEC protocol. There are also sometimes children with only small number of gas bubbles in the portal vein or superior mesenteric vein. We would observe them closely. Most of these cases resolve spontaneously without sequelae, we sometimes even continue feeds.

I remember a preemie approaching discharge in whom the only etiology we could associate portal gas with was cow milk protein allergy. The baby was fine, discharged home with intermittent pneumatosis. On the other hand, very recently I had a term baby who presented with unilateral seizures and was diagnosed with left-sided MCA infarct. On presentation I noticed massive hepatic/portal pneumatosis with gas transfer to IVC via open venous duct and to the systemic circulation via PFO. I was wondering whether air embolism could have been responsible for neurological presentation in that child. Also, pneumatosis usually preceeds other clinical symptoms, like in this case - this baby developed enterocolitis symptoms 24hours later, without any clinical symptoms on the initial presentation.

On a different note, couple years back we almost completely eliminated X-ray for assessment of abdominal symptoms. We now rely on ultrasound which provides more data, is obviously not associated with radiation exposure and unlike x-ray allows for continous assessment.

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  • 2 weeks later...

Hi Stefan,

My question is on the lines of NEC.

Is gastric decompression routinely dobe in NEC/suspected NEC cases? If not why not? Some references would be appreciated?

We were trained to do it to prevent perforation but some people don't seem to believe in it.

Thanks for your feedback

Mosarrat Qureshi

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Stefan, this is a difficult problem for 2 reasons: uncertainty with diagnosis of NEC, and limited evidence on what constitutes adequate treatment for NEC of various degrees of severity.

The diagnosis of pneumatosis intestinalis versus gas bubbles in stool is difficult; there is commonly lack of agreement on the presence of pneumatosis, and the interpretation is easily biased by other clinical findings. Sometimes, babies with questionable pneumatosis are labeled as having non-specific colitis, or (protein)-allergic colitis, and they may be treated with only bowel rest, or additionally a couple of days of antibiotics, and feedings resumed in 3-5 days if radiological and clinical exams are reassuring. Some neonatologists will have a lower threshold for diagnosing NEC (could be Bell stage 2 in the scenario you gave) and treating for at least 7 days.

Even when there is consensus on the presence of pneumatosis, the extent and location of pneumatosis may be important; for example, isolated colonic pneumatosis tends to be seen in older babies and it has a milder clinical presentation. We usually treat for at least 7 days, though some babies' abnormal findings may resolve in 2 or 3 days.

I have not seen evidence on gastric decompression. It makes physical sense that intestinal distension and increased intra-abdominal pressure would tend to decrease intestinal blood flow, and they might also cause discomfort to the patient, so we start gastric suction early, until distension and other signs such as bilious aspirates resolve; then, we leave the orogastric tube to gravity drainage. 

I hope this helps.

Joaquim Pinheiro, MD, MPH

Professor of Pediatrics

Albany, NY, USA

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On 2/3/2019 at 7:03 PM, Stefan Johansson said:

@satyen75 - thanks for your input. Do I understand you correctly that you do not set the "NEC" label on x-ray findings of intramural gas, IF lab results and clinical signs are all normal?

Here's two references on the problem:





Yes, It is not pathognomic of NEC . A holisitic picture if it fits along with Xray should be considered to label NEC.

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