Pneumatosis intestinalis revisited: associated imaging findings, clinical correlation, management, risk stratification and future perspectives

BACKGROUND: Pneumatosis intestinalis (PI) is the imaging finding of air within the bowel wall. It constitutes a diagnostic challenge due to its broad differential and overlap in imaging appearances between benign and serious causes. A multidisciplinary approach is essential for accurate diagnosis and timely intervention, to optimize outcomes and minimize unnecessary procedures. OBJECTIVE: This article aims to synthesize the literature to lay out the current state of the art in diagnosing and managing PI and discuss future perspectives. We review a series of associated imaging features including portomesenteric venous gas, vascular thrombosis, abnormal bowel wall enhancement, and bowel wall thickening or thinning. We also discuss less specific but commonly seen findings like pneumoperitoneum, ascites and fat stranding, emphasizing their context-dependent significance. We review nuances in clinical interpretation of the severity of PI, discuss the discordance in interpretation of certain clinical markers, and important considerations in specific populations. To finish, we describe ongoing efforts related to risk stratification and its importance in PI management.