*Purpose: Isolated pneumatosis intestinalis after solid organ transplantation, as well as its surgical management in appropriate clinical context, is a well described entity. The management of concurrent pneumoperitoneum, however, is not as well understood. Consequently, we present three interesting cases of pneumatosis intestinalis with pneumoperitoneum where conservative management was warranted.

*Methods: We present three cases of solid organ transplant patients demonstrating both operative and nonoperative management of benign pneumatosis intestinalis with pneumoperitoneum.

*Results: Case #1: A 61-year-old male underwent deceased-donor liver transplant. The patient was found to have incidental, asymptomatic pneumoperitoneum on routine postoperative surveillance imaging at nine months, with evidence of pneumatosis intestinalis. Consequently the patient was surgically explored, resulting in no discernable cause. Case #2: A 75-year-old male underwent deceased-donor kidney transplant. Three months postoperatively the patient presented to clinic with diarrhea. Subsequent diagnostic imaging displayed pneumoperitoneum with pneumatosis intestinalis. This patient was also surgically explored, resulting in no discernable cause. Case #3: A 60-year-old female underwent a living- donor liver transplant. Eight months postoperatively she presented with incidental pneumoperitoneum and pneumatosis intestinalis. Interval imaging showed worsening pneumoperitoneum in addition to development of intraabdominal fluid collections. With the absence of identifiable cause and inconsistent symptoms this patient was successfully managed conservatively with antibiotics, percutaneous drainage and bowel rest.

*Conclusions: Given the high index of suspicion for a hollow viscus perforation and the mortality associated with sepsis in the immunosuppressed patient, surgeons feel obligated to explore these subsets of patients. However, as depicted in each of the three described cases, nonoperative management is often an acceptable alternative in appropriate clinical context.

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