British Journal of Radiology (2006) 79, e32-e35
© 2006 British Institute of Radiology
doi: 10.1259/bjr/57839881
Intravasation of barium sulphate at barium enema examination
J S White, BMedSci(Hons), PhD, FRCS,
R T Skelly, MB, FRCS,
K R Gardiner, MD, MCh, FRCS,
J Laird, FRCR and
M C Regan, MD, FRCS
Correspondence: Mr Jonathan S White, Royal Alexandra Hospital, 10240 Kingsway, Edmontion, AB, T5H 3V, Canada
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Abstract
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We report a case of venous intravasation of barium sulphate occurring during a routine barium enema examination for investigation of rectal bleeding. The patient suffered a cardiopulmonary arrest, but made a full recovery after organ support in intensive care. Review of radiographs from the examination showed intravasated barium in pelvic vessels. We review the literature on this rare, but serious, complication of barium enema examination and suggest measures by which intravasation can be prevented.
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Case report
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Over 15 000 barium enema examinations are performed annually in Northern Ireland. Circulatory intravasation of barium sulphate is a rare, but potentially fatal, complication of this procedure. We report a case of barium intravasation occurring during a routine barium enema examination.
A 77-year-old woman was admitted with a short history of passing dark blood mixed with the stool. She had a history of colonic diverticular disease, hypertension, previous stroke and exertional angina. Digital rectal examination, gastroscopy and rigid sigmoidoscopy were normal. Barium enema examination was carried out using a balloon catheter, which was placed and inflated by an experienced radiographer. Barium sulphate was instilled and screening commenced. Contrast was noted in a linear structure outside the rectum and instillation of barium was halted, the balloon deflated and the catheter removed. The chest and abdomen were screened for signs of barium, but none were apparent. Within a few minutes, the patient complained of feeling faint and suffered a cardiopulmonary arrest. Cardiopulmonary resuscitation was successful and the patient was transferred to intensive care, where she required ventilatory and supportive therapy. Electrocardiography and cardiac enzyme profiles were normal and there were no neurological findings suggesting a cerebrovascular event. The patient developed disseminated intravascular coagulation, which responded to treatment with fresh frozen plasma and platelets. After 3 days in intensive care, she returned to the ward. Review of the barium enema radiographs confirmed the presence of barium sulphate in pelvic veins, consistent with intravasation from the vagina (Figure 1
), although examination per rectum and per vagina showed no evidence of injury. The patient subsequently made a full recovery and returned home again.
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Figure 1. Screening radiograph from barium enema examination showing intravasation of barium sulphate into pelvic veins from a presumed vaginal injury.
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Discussion
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Barium enema, one of the most common radiological investigations, is considered safer than colonoscopy as an investigation for colorectal symptoms [1, 2]. The most common serious complication of barium enema is colonic perforation, which occurs in 0.004–0.04% of procedures [3–5]. Barium may also intravasate into the venous drainage of the large bowel and enters the circulation as a "barium embolus". This complication occurs rarely: in addition to the case described here, 36 cases of barium intravasation have been reported in the last 50 years [6–25] (Table 1).
Barium intravasation due to rectal injury at the time of barium enema is thought to account for 8 of the 36 cases reported. Thinning of the rectal wall with age and proximity of the haemorrhoidal venous plexus may contribute to intravasation [6]. Intravasation at a site in the colon affected by disease accounted for a further 12 cases. It is thought to occur when intraluminal pressure overcomes the resistance of the colonic wall affected by colitis, diverticulitis or intestinal obstruction [7, 26]. 14 cases of barium intravasation occurring after vaginal insertion of the rectal catheter have also been reported [8–10, 13, 16]. These cases occur most often in elderly patients [8] and contributing factors include deficient perineal musculature, patient confusion, age-related vaginal thinning and use of a balloon catheter, which may prevent reflux of barium from the vagina [19]. In the two remaining cases, the site of barium entry into the venous system was unclear.
Barium intravasating from the lower rectum or vagina enters the internal iliac venous system and is carried in the systemic circulation to the lungs, where it causes occlusion of the pulmonary circulation. Barium may also circulate within the systemic circulation to the heart, kidney and brain [8]. Barium intravasating from the upper rectum and colon enters the portal circulation and is carried to the liver before entering the systemic circulation. The mortality associated with portal embolisation is much lower than that for systemic embolisation (25% vs 60%, Table 1
); this is probably because hepatic reticuloendothelial cells take up barium and reduce the amount entering the systemic circulation [6]. Portal intravasation tends to affect a younger age group than systemic intravasation (average age 44 years vs 77 years, Table 1); this may reflect a decreased likelihood of vaginal injury in younger patients due to better vaginal sensation. Systemic emboli also tend to involve a larger amount of barium with more significant cardiovascular effects [6].
As intravasation of barium sulphate is encountered very rarely, it may be difficult to recognize. It may be detected during screening at the start of the examination: if this is the case, it is recommended that the enema table is tilted to a "head up" position and the patient turned to the right to retard the passage of barium into the pulmonary circulation [27]. A plain pelvic radiograph may be helpful in establishing the diagnosis: Zatkin and Irwin described barium within the pelvic veins as a tangled mass of tubular structures resembling a "Medusa's head" [28]. In portal intravasation, specific vessels such as the inferior mesenteric vein may be visible on plain radiography [7], and may be mistaken for contrast within the ureter [18]. Barium may also be detected within the liver, spleen, heart or lung on plain radiographs of chest and abdomen. CT is effective in demonstrating barium within the lungs and solid organs [15], but MRI is of little benefit [22].
Of the 37 cases of venous intravasation of barium sulphate reported to date, 18 (48.6%) proved fatal. Mortality in patients under 60 years of age was much lower than for those over 60 years (17% vs 64%, Table 1). Massive systemic embolisation usually causes immediate circulatory arrest; if a lesser amount of barium is involved, death may occur a few hours or days after the incident [6, 7, 16]. In younger patients in whom a small amount of barium enters the portal venous system, recovery is likely with supportive management. Patients with respiratory distress require endotracheal intubation and ventilation in an intensive care unit, with monitoring and support of cardiac, renal and hepatic function. Coagulation may be impaired after intravasation of barium and transfusion of clotting factors may be required [29]. Some authors have reported survival following treatment with corticosteroids and antibiotics [6]. Indications for surgery in the management of barium intravasation are unclear. Of the eight cases in which surgical intervention was attempted, four survived following partial colectomy [12, 18, 20, 30] while four others perished following laparotomy, attempted vaginal drainage or colectomy [8, 21, 27].
Two main strategies have been suggested to prevent barium intravasation at barium enema: confirmation of correct placement of the rectal catheter and reduction of the use of balloon catheters. It has been proposed that an appropriately-trained member of staff should inspect the perineum and perform a digital rectal examination before guiding the catheter into the rectum. A small amount of barium or air may also be insufflated at the start of screening, with the patient in a lateral position, to confirm that the catheter is correctly placed and to inspect the point of contact of the rectal catheter with the rectal wall [13, 19, 31]. There is considerable controversy over use of balloon catheters at barium enema. 20 of the 37 reports of barium intravasation were associated with use of a balloon catheter (Table 1). Over-inflation of the balloon may cause direct injury to the rectum or vagina; the balloon also prevents barium reflux, producing higher inflation pressures and increasing the risk of perforation or intravasation [17, 26]. Other authors believe that balloon catheters are safe if used carefully [30]. According to a recent UK survey, 22% of radiologists employ a balloon catheter routinely for barium enema and a further 43% use such a catheter occasionally, although only 5% follow all of the published safety recommendations, such as examining the rectal wall digitally before the balloon is inflated [31, 32]. The same study suggested that extraperitoneal perforation of the colon at barium enema was 2.5 times more likely when a balloon catheter was used: some centres have subsequently chosen to abandon the balloon catheter for routine use in barium enema. Close control of inflation pressures during the examination can be achieved by limiting the height of the barium bag, or by the use of pressure-controlled insufflation systems, and may reduce the risk of intravasation of barium. Subsequent to the case reported here, several changes were made in the practice of barium enema in this unit: reduction of the use of balloon catheters, pre-screening with air, careful initial screening with barium and control of insufflation pressure (Table 2). It is hoped that these measures will reduce the chances of encountering a further example of this serious complication of barium enema.
In conclusion, intravasation of barium sulphate at barium enema is a rare complication of a common procedure and is associated with a high mortality rate. It is more likely to occur in elderly patients and in those with colorectal disease and has been associated with inadvertent vaginal placement of the rectal catheter. The diagnosis should be considered in any patient who collapses during or shortly after barium enema, and in those who become suddenly unwell in the hours following the procedure. The diagnosis can be confirmed by simple plain radiography; CT scanning may also be useful to detect dissemination of barium sulphate. Survival is more likely in younger patients, in cases of embolisation to the portal circulation and in those cases in which only a small amount of barium is involved. In those patients who survive the initial insult, conservative management with support of organ function is often successful. The complication may be prevented by ensuring correct placement of the rectal catheter and by reducing the use of balloon catheters.
Received for publication April 18, 2005.
Revision received August 12, 2005.
Accepted for publication September 2, 2005.
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Abstract
Case report
