Gaja Shaughnessy

A Rare Complication of a Barium-Contrast Study

n 86-year-old woman was admitted for intracAtable vomiting and septic pneumonia. Her medical history included refractory peptic ulcer disease requiring Billroth II gastrectomy, complicated by gastric outlet obstruction with placement of gastrostomy and jejunostomy tubes. She reported having a barium swallow study for vomiting a week prior, after which her symptoms worsened progressively. She complained of diffuse abdominal pain, distension, and was uncertain of the timing of her last bowel movement. Physical examination was notable for a heart rate of 119 beats per minute, blood pressure of 75/35 mm Hg, and a distended tender abdomen with minimal bowel sounds throughout. Laboratory findings showed a hemoglobin level of 8.2 g/dL, a white blood cell count of 12.2 10/L, a creatinine level of 1.6 mg/dL, and a lactic acid level of 2.6 mmol/L. An abdominal radiograph and computed tomography scan of the abdomen and pelvis showed diffuse colonic and distal small-bowel dilatation with hyperdense intraluminal material and areas of focally dense intraluminal contents within the proximal descending colon corresponding with inspissated barium (Figures A and B). She was treated for septic shock with vasopressor support and showed hemodynamic improvement by the third day. Conservative management was attempted to relieve the barium impaction. No results were produced using polyethylene glycol, sodium polystyrene sulfonate, lactulose enemas, tap water enemas, mineral oil enemas, or manual disimpaction. Sigmoidoscopy on day 4 of the hospitalization showed large barium pellets; irrigation was attempted without success (Figure C). The patient underwent total colectomy with end-ileostomy on day 6 of the hospitalization. She was discharged in stable condition. Barium sulfate is an insoluble salt commonly used in radiologic studies and generally is considered a low-risk contrast medium. Rarely, it can precipitate and cause impaction. One systematic review found only 32 reported cases of bowel obstruction caused by barium inspissation that occurred over a 56-year period (1950–2006). Risk factors include advanced age, electrolyte imbalances, dehydration, changes to intestinal anatomy narrowing the lumen, and any drugs or medical conditions affecting colon motility (systemic lupus erythematosus, scleroderma, Parkinson’s disease, diabetes, or Ogilvie’s syndrome). Nearly half of the cases manifested themselves within the first 4 weeks after barium studies, however, it may take up to 2 years for this to occur. Methods used to relieve barium impaction in the past have been manual extraction, enemas, laxatives, and endoscopy. Colonoscopic dissolution was achieved using either high-pressure jet stream under general anesthesia, prolonged water irrigation, or combined mechanical destruction and irrigation. Nearly half of the cases required surgery, ranging from colotomy with barolith removal to total colectomy with ileostomy. Considering

71-Year-Old Woman With Abdominal Pain

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Jacksonville, FL (G.F.S., S.P.S.); Advisor to residents and Consultant in Community Internal Medicine, Mayo Clinic, Jacksonville, FL (M.S.H.). A 71-year-old woman presented to the emergency department with abdominal pain of 6 days’ duration. She described the pain as being severe, crampy, nonradiating, and in the left lower quadrant. The pain was associated with nausea and fevers. She had decreased appetite but no episodes of vomiting, tenesmus, rectal pain, diarrhea, hematochezia, melena, or dysuria. Her medical history was notable for constipation, an episode of diverticulitis treated with antibiotics, an incarcerated ventral hernia that was repaired with biologic mesh, and an appendectomy. Her medications included sertraline and a multivitamin. The patient was allergic to penicillin and was intolerant of metronidazole. On physical examination, her temperature was 37.2 C, heart rate was 98 beats/min, blood pressure was 156/89 mm Hg, and respiratory rate was 18 breaths/min. She was alert, oriented, slightly anxious, and in no acute distress. Her lungs were clear on auscultation. Her cardiovascular examination results were unremarkable. Her abdomen was soft and nondistended without rebound or rigidity, but she reported tenderness in the left lower quadrant. She had a large ventral hernia with palpable fascial margins and easily reducible contents. She had no costovertebral angle tenderness. Laboratory studies revealed the following (reference ranges provided parenthetically): hemoglobin, 13.5 g/dL (12.0-15.5 g/dL); white blood cell count, 15.8 10/L (3.5-10.5 10/L); platelet count, 319 10/L (150-450 10/L); total bilirubin, 0.8 mg/dL ( 1.2 mg/dL); direct bilirubin, 0.2 mg/dL (0.0-0.3 mg/dL); alkaline phosphatase, 120 U/L (55-142 U/L); alanine aminotransferase, 15 U/L (7-45 U/L); aspartate aminotransferase, 19 U/L (8-43 U/L); and lipase, 18 U/L (10-73 U/L). Results of a comprehensive metabolic panel were unremarkable. Urinalysis revealed a small amount of leukocyte esterase, trace proteins, 4 white blood cells per high-power field, 3 red blood cells per high-power field, and the presence of bacteria.