P1.056: Resource Utilization and Surgical Risk in Pediatric Pneumatosis Intestinalis: A Single-Institution Analysis

Background: Pneumatosis intestinalis (PI) in children, excluding cases related to necrotizing enterocolitis (NEC), is primarily managed non-operatively with bowel rest, antibiotics, and total parenteral nutrition (TPN). However, it is unclear how best to estimate the risk of PI requiring surgical intervention, complicating decision-making regarding the length of treatment necessary for PI. This study reviewed children with non-NEC PI to understand current management and evaluate factors associated with surgical intervention for PI.

Methods: A retrospective chart review of patients aged six months to 21 years with PI from 2010-2023 was conducted at a free-standing children’s hospital. Patients were identified using relevant ICD-9 and ICD-10 diagnosis codes for pneumatosis. Those with diagnosis of NEC within the prior six months of PI or a history of abdominal surgery within the prior three months of PI were excluded.

Results: A total of 102 patients with 139 unique encounters for PI were included. Median age was 4.5 years (IQR: 2.0–13.0); 30 (29%) had an underlying genetic disorder, 22 (22%) had a history of malignancy, 17 of whom were undergoing active treatment at the time of PI, and 13 (13%) had congenital cardiac defects that had required previous surgical intervention. PI was identified in 98 encounters (71%) via X-ray alone, 35 (25%) via CT alone, and 5 (4%) via combination of X-ray and CT. In 23 encounters (16.5%), PI was an incidental imaging finding. Patients received a mean of 7.2 days of antibiotics, 7.1 days of TPN, 6.4 days of nil per os, 5.1 days of gastric decompression, and 5.7 imaging studies per PI encounter. After initial conservative management with bowel rest, antibiotics, and TPN, surgical exploration was completed in five encounters (3.6%) due to the development of pneumoperitoneum (20%), radiologic progression of pneumatosis (100%), persistent or new-onset tachycardia (60%), fevers (60%), and/or worsening abdominal pain/distention (100%). All who required surgical intervention had colonic pneumatosis and complex conditions such as neurologic impairment, gastrointestinal dysmotility, immunocompromise, or congenital cardiac anomaly. Of the five patients who underwent surgery, one had a negative exploration, and four underwent bowel resections. Two resections were due to colonic necrosis, and both patients had radiographic progression, tachycardia, and persistent fevers. Two resections were performed only for dysmotility-related reasons in patients with preexisting motility disorders.

Conclusion: Each diagnosis of non-NEC pediatric PI led to approximately one week of antibiotics, bowel rest, and TPN. The need for surgical intervention was uncommon and occurred only in those with colonic pneumatosis, underlying comorbidities, fevers, and new or persistent tachycardia. Prolonged non-operative management may be unnecessary for many low-risk patients. Future work using a larger, multi-institutional sample of patients may enable clinicians to better identify high-risk patients while reducing unnecessary treatment in lower-risk patients.