Mesenteric Pneumatosis on CT: A Predictor of Benign Pneumatosis Intestinalis

Purpose To determine whether specific CT findings, particularly mesenteric pneumatosis, can help differentiate benign from life-threatening pneumatosis intestinalis (PI). Methods This retrospective study included adult patients with PI identified on abdominal CT between January 2013 and December 2022. Two radiologists analyzed CT features, including PI location and extent, circumferential gas, mesenteric pneumatosis, portomesenteric venous gas, decreased mural enhancement, bowel dilatation, mesenteric fat stranding, free peritoneal air, and free peritoneal fluid. Patients were classified as having benign or life-threatening PI based on clinical outcomes. Statistical analyses were performed to identify predictors of life-threatening PI. Results A total of 215 patients were included, with 72 (33%) classified as benign PI and 143 (67%) as life-threatening PI. Multivariate analysis identified portomesenteric venous gas (p = 0.001, OR = 7.53), decreased mural enhancement (p < 0.001, OR = 13.18), and free peritoneal fluid (p = 0.011, OR = 5.39) as independent predictors of life-threatening PI. Mesenteric pneumatosis (p = 0.002, OR = 0.09) was an independent predictor of benign PI. Bowel ischemia was the most common etiology of PI, accounting for 61.9% of cases. Conclusion Mesenteric pneumatosis is a key predictor of benign PI, while decreased mural enhancement, portomesenteric venous gas, and free peritoneal fluid indicate life-threatening PI. These findings aid in identifying patients requiring urgent intervention while helping to avoid unnecessary surgery in benign cases.