Intestinal pneumatosis in the newborn as a differential diagnostic challenge
Authors:
S. Krasulová; K. Maťašová jr.; F. Chovancová; L. Časnocha Lúčanová
Authors‘ workplace:
Neonatologická klinika, Univerzitná nemocnica Martin, Jesseniova lekárska fakulta v Martine, Univerzita Komenského v Bratislave
Published in:
Čes-slov Neonat 2026; 32 (1): 19-26.
Category:
Original Paper
Overview
Finding of pathological gas in the intestinal wall is considered a sign of necrotizing enterocolitis in newborns. Pneumatosis intestinalis in association with the presence of gas in the portal vein or pneumoperitoneum usually represents an acute condition requiring prompt intervention. However, the causes of intestinal pneumatosis can be different, and it may not always be caused by a life-threatening illness. The work presents the general etiopathogenesis of intestinal pneumatosis and summarizes its possible causes. Pneumatosis intestinalis can be a consequence not only of necrotizing enterocolitis, but also of cow›s milk protein allergy or infectious gastroenteritis. In the early stages of the disease, abdominal ultrasonography may be useful to differentiate necrotizing enterocolitis. The prognostic significance of intestinal pneumatosis in newborns is ambiguous due to the diverse etiopathogenesis.
Keywords:
cow’s milk protein allergy – necrotizing enterocolitis – pneumatosis intestinalis
Sources
1. Bednarczyk MM, Żelazna O, Głuszczak-Idziakowska E, Schreiber-Zamora J, Furmanek M, Kociszewska-Najman B. A case of necrotizing enterocolitis in full-term infant on his first day of life-Early presentation with multifactorial etiology. Clin Case Rep 2023; 11(4): e7150. Dostupné z: https://doi. org/10.1002/ccr3.7150.
2. Burris AD, Burris J, Järvinen KM. Cow›s milk protein allergy in term and preterm infants: clinical manifestations, immunologic pathophysiology, and management strategies. Neoreviews 2020; 21(12): e795–e808. Dostupné z: https://doi.org/10.1542/ neo.21-12-e795.
3. Chen S, Hu Y, Liu Q, Li X, Wang H, Wang K, Zhang A. Application of abdominal sonography in diagnosis of infants with necrotizing enterocolitis. Medicine (Baltimore) 2019; 98(28): e16202. Dostupné z: https://doi.org/10.1097/MD.0000000000016202.
4. Chen Q, Yao W, Xu F, Liao J, Li J, Mai M, Xie H, He X, Li N. Application of abdominal ultrasonography in surgical necrotizing enterocolitis: a retrospective study. Front Microbiol 2023; 14 : 1211846. Dostupné z: https://doi.org/10.3389/fmicb.2023.1211846.
5. Coskun Y, Özen MA, Kayas K, Arikan C, Gursoy T. Pneumatosis intestinalis: Does it always indicate necrotizing enterocolitis? Turk J Pediatr 2024; 66(6): 768–774. Dostupné z: https://doi. org/10.24953/turkjpediatr.2024.5308.
6. Cuna A, Kumar N, Sampath V. Understanding necrotizing enterocolitis endotypes and acquired intestinal injury phenotypes from a historical and artificial intelligence perspective. Front Pediatr 2024; 12 : 1432808. Dostupné z: https://doi.org/10.3389/ fped.2024.1432808.
7. Cuna AC, Lee JC, Robinson AL, Allen NH, Foley JE, Chan SS. Bowel ultrasound for the diagnosis of necrotizing enterocolitis: a meta-analysis. Ultrasound Q 2018; 34(3): 113–118. Dostupné z: https://doi.org/10.1097/RUQ.0000000000000342.
8. Du Vernoy JG. Aer intestinorum tam sub extima quam intima tunica inclusus: observationes anatomicae: comment. Acad Acient Imp Petropol 1730; 5 : 213–225.
9. Gnocchi M, Gagliardi M, Gismondi P, Gaiani F, de’ Angelis GL, Esposito S. Updated management guidelines for Clostridioides difficile in paediatrics. Pathogens 2020; 9(4): 291. Dostupné z: https://doi.org/10.3390/pathogens9040291.
10. Goldberg E, Lamont JT. Pneumatosis intestinalis. In: UpToDate, 2025. Dostupné z: https://www.uptodate.com/contents/pneumatosis-intestinalis#H2858993090, [citované 2026-01-09].
11. Guo Y, Si S, Jia Z, Lv X, Wu H. Differentiation of food protein-induced enterocolitis syndrome and necrotizing enterocolitis in neonates by abdominal sonography. J Pediatr (Rio J) 202; 97(2): 219–224. Dostupné z: https://doi.org/10.1016/j. jped.2020.03.001.
12. Havlíčeková Z. Alergia na bielkovinu kravského mlieka: ako zvoliť náhradnú mliečnu formulu? Pediatria (Bratisl.) 2021; 16(4): 171–174.
13. Hoehn T, Stöver B, Bührer C. Colonic pneumatosis intestinalis in preterm infants: different to necrotising enterocolitis with a more benign course? Eur J Pediatr 2001; 160(6): 369–371. Dostupné z: https://doi.org/10.1007/s004310100757.
14. Kim JH. Neonatal necrotizing enterocolitis: clinical features and diagnosis. In: UpToDate, 2025. Dostupné z: https://www. uptodate.com/contents/neonatal-necrotizing-enterocolitis-clinical-features-and-diagnosis, [citované 2026-01-09].
15. Kuiper GA, van Prehn J, Ang W, Kneepkens F, van der Schoor S, de Meij T. Clostridium difficile infections in young infants: case presentations and literature review. IDCases 2017; 10 : 7–11. Dostupné z: https://doi.org/10.1016/j.idcr.2017.07.005.
16. Kurbegov AC, Sondheimer JM. Pneumatosis intestinalis in non-neonatal pediatric patients. Pediatrics 2001; 108(2): 402 – 406. Dostupné z: https://doi.org/10.1542/peds.108.2.402.
17. Lassandro G, Picchi SG, Romano F, Sica G, Lieto R, Bocchini G, Guarino S, Lassandro F. Intestinal pneumatosis: differential diagnosis. Abdom Radiol (NY) 2022; 47(5): 1529–1540. Dostupné z: https://doi.org/10.1007/s00261-020-02639-8.
18. Mani S, Hazra S, Hagan J, Sisson A, Nair J, Pammi M. Viral infections and neonatal necrotizing enterocolitis: a meta-analysis. Pediatrics 2023; 152(1): e2022060876. Dostupné z: https://doi. org/10.1542/peds.2022-060876.
19. Moak R, Boone N, Eidson N, Rohrer A, Engevik M, Williams K, Chetta K. Exploring the links between necrotizing enterocolitis and cow›s milk protein allergy in preterm infants: a narrative review. Front Pediatr 2023; 11 : 1274146. Dostupné z: https://doi. org/10.3389/fped.2023.1274146.
20. Morita Y, Iwakura H, Ohtsuka H, Kohno Y, Shimojo N. Milk allergy in the neonatal intensive care unit: comparison between premature and full-term neonates. Asia Pac Allergy 2013; 3(1): 35–41. Dostupné z: https://doi.org/10.5415/apallergy.2013.3.1.35.
21. Neu J. Necrotizing enterocolitis: the future. Neonatology 2020; 117(2): 240–244. Dostupné z: https://doi. org/10.1159/000506866.
22. Nicholson MR, Statler VA. Clostridioides difficile infection in children: clinical features and diagnosis. In: UpToDate, 2025. Dostupné z: https://www.uptodate.com/contents/clostridioides-difficile-infection-in-children-clinical-features-and-diagnosis, [citované 2026-01-09].
23. Neu J, Modi N, Caplan M. Necrotizing enterocolitis comes in different forms: historical perspectives and defining the disease. Semin Fetal Neonatal Med 2018; 23(6): 370–373. Dostupné z: https://doi.org/10.1016/j.siny.2018.07.004.
24. Short SS, Papillon S, Berel D, Ford HR, Frykman PK, Kawaguchi A. Late onset of necrotizing enterocolitis in the fullterm infant is associated with increased mortality: results from a two-center analysis. J Pediatr Surg 2014; 49(6): 950–953. Dostupné z: https://doi.org/10.1016/j.jpedsurg.2014.01.028.
25. Sullivan S, Schanler RJ, Kim JH, Patel AL, Trawöger R, KiechlKohlendorfer U, Chan GM, Blanco CL, Abrams S, Cotten CM, Laroia N, Ehrenkranz RA, Dudell G, Cristofalo EA, Meier P, Lee ML, Rechtman DJ, Lucas A. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr 2010; 156(4): 562–567.e1. Dostupné z: https://doi.org/10.1016/j.jpeds.2009.10.040.
26. Vardar G, Ozdil M, Tufekci S. Awareness or neglecting the diagnosis of cow milk protein allergy in the neonatal period. Asia Pac J Clin Nutr 2023; 32(2): 257–264. Dostupné z: https:// doi.org/10.6133/apjcn.202306_32(2).0008.
27. Vaz Ferreira MC, Moraes M. Necrotizing enterocolitis in a full term infant. Arch Clin Cases 2016; 3(4): 115–119. Dostupné z: https://doi.org/10.22551/2016.13.0304.10079.
28. Wang YJ, Wang YM, Zheng YM, Jiang HQ, Zhang J. Pneumatosis cystoides intestinalis: six case reports and a review of the literature. BMC Gastroenterol 2018; 18(1): 100. Dostupné z: https:// doi.org/10.1186/s12876-018-0794-y.
29. Weitkamp JH, Premkumar MH, Martin CR. Necrotizing enterocolitis. In: Eichenwald EC, Hansen AR, Martin CR, Stark AR. Cloherty and Stark´s Manual on Neonatal Care. 8th ed. New Delhi: Wolters Kluwer 2021; 367–379.
Labels
Neonatology Neonatal NurseArticle was published in
Czech and Slovak Neonatology
2026 Issue 1
Most read in this issue
- Hematemesis in a newborn
- Management and complications of short bowel syndrome in the context of pathophysiological changes
- Cystic lesions in the oral cavity of a neonate
- Lactobezoar – a rare cause of intestinal obstruction in a preterm newborn