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digestive pneumatosis

Tuesday 1 July 2003

Digital cases

- Case 226: Parietal pneumatosis in neonatal necrotic enterocolitis

Definition: Pneumatosis intestinalis is characterized by the accumulation of gas in the gastrointestinal wall.

The histopathologic diagnosis is easily made on resection specimens in which the presence of submucosal or subserosal empty spaces lined by histiocytes and giant cells presents little diagnostic dilemma.

In biopsy material, though, the diagnosis is more challenging, as giant cells and histiocytes can be interpreted as granulomatous inflammation indicative of other conditions such as infection or Crohn disease.


- pseudo-polyps
- raised mucosal folds
- submucosal cystic spaces lined by giant cells
- giant cells lining a rounded or cleftlike space
- pseudolipomatosis
- round empty spaces in the submucosa resembling fat
- nonspecific findings

  • variable inflammation
  • eosinophilia
  • mild gland disarray
  • vascular ectasia
  • edema
  • mild melanosis coli

Differential diagnosis

- granulomatous inflammation

  • granulomatous colitis
    • Crohn disease


- acquired immunodeficiency syndrome (AIDS)
- ischemic colitis
- cytomegalovirus colitis


- intestinal pneumatosis
- colonic pneumatosis


- cryptitis
- crypt abscesses
- mucosal chronic inflammation
- mucosal granulomas
- crypt dilation
- partial crypt rupture
- intramucosal cysts
- clusters of small gas cysts in the lamina propria.


- neonatal necrotizing enterocolitis (NNEC)
- anaerobial bacterial enterocolitis
- high intraluminal pressure


- healthy children (22%)
- organ and bone marrow transplant (22%)
- decompensated congenital heart disease (12.5%)

- gastroschisis (9%)
- short bowel syndrome (6%)

- most common events immediately preceding

  • noninfectious colitis (32%)
  • acute enteric infection or toxin (27%)
  • bowel ischemia (20%)
  • gastrointestinal dysmotility (17%)
  • graft versus host disease colitis

See also

- Pneumatosis

  • hepatic pneumatosis
  • cerebral pneumatosis


- Koreishi A, Lauwers GY, Misdraji J. Pneumatosis intestinalis: a challenging biopsy diagnosis. Am J Surg Pathol. 2007 Oct;31(10):1469-75. PMID: 17895747

- Pieterse AS, Leong AS, Rowland R. The mucosal changes and pathogenesis of pneumatosis cystoides intestinalis. Hum Pathol. 1985 Jul;16(7):683-8. PMID: 4007844