Barium peritonitis. Experience of five pediatric cases

Perforation of barium sulfate enterography in an infant: A case report

RATIONALE

Barium peritonitis is an inflammatory response that occurs when barium accidentally enters the abdominal cavity during a barium test. In extreme circumstances, it has the potential to harm various organs and even result in death.

PATIENT CONCERNS

A 3-month-old infant was diagnosed with multiple organ failure after severe barium peritonitis.

DIAGNOSIS

Multiple organ dysfunction is associated with barium peritonitis.

INTERVENTIONS

The infant underwent surgical intervention and received ventilator support, anti-infection therapy, myocardial nutrition, liver and kidney protection, rehydration, circulation stabilization, and other symptomatic supportive care.

OUTCOMES

The patient experienced clinical death after treatment and resuscitation was unsuccessful.

LESSONS

Barium enema perforation complications are uncommon, but can lead to fatal injuries with a high mortality rate. This case highlights the importance of raising awareness among clinicians about the risks of gastroenterography in infants and children and actively preventing and avoiding similar serious complications. The mortality rate can be reduced by timely multidisciplinary consultation and joint management once a perforation occurs.

Intestinal obstruction from inspissated barium (Barolith): a systematic review of all cases from 1950 to 2006

OBJECTIVE

Having encountered a case of large bowel obstruction secondary to a barolith and successfully treated it using colonoscopic dissolution, we systematically reviewed all cases of barolith obstruction to appreciate its incidence and explore its methods of treatment.

METHOD

A literature search was carried out in the databases British Nursing Index, Cinahal, Embase, Medline, and Pub Med. There was no restriction placed on language of publication in the search.

RESULTS

There were 22 reports describing a total of 31 cases. About one third of the reported cases were successfully treated with conservative measures including the use of laxatives. Significantly, surgery was performed in nearly half of the patients. Interestingly, endoscopic dissolution was attempted in only 3 cases and it was successful in all of them.

CONCLUSION

This systematic review reveals several reported cases of barolith obstruction from 1950-2006. Only three case reports described colonoscopic dissolution. In our institute, we have recently encountered a case of large bowel obstruction secondary to a barolith and we successfully treated it using colonoscopic dissolution. Given the absence of guidelines to treat barolith induced obstruction, we are of the opinion that should a barolith obstruction occur, in the absence of perforation or ischaemic bowel, endoscopic dissolution by an experienced endoscopist under general anaesthetic offers a safe, effective, and minimally invasive method of relieving the obstruction. Should this fail surgery is indicated.

Perforation associated with barium enema in acute appendicitis

A child with the suspected diagnosis of atypical acute appendicitis underwent a diagnostic barium enema. The study was complicated by perforation with leakage of a large amount of barium into the peritoneal cavity. The complex hospital course that resulted has prompted us to reevaluate the barium enema in the diagnosis of appendicitis and review the literature for contraindications. We conclude that this particular complication is extremely rare and that barium enema still has a part to play in some patients where the clinical diagnosis is uncertain.

Rectal perforation during barium enema. Report of a case

Perforation of the colon or rectum during the course of barium-enema examination is estimated to occur in approximately 500 patients annually in the United States. It has been over 30 years since the last collective review on this subject reported a prohibitively high mortality and morbidity. Since that time, much has been learned about the treatment of patients with peritonitis and bowel perforation, many new and more effective antibiotics have become available, and the management of shock has become infinitely more sophisticated. A review of recently reported cases suggests that the mortality rate and possibly the early morbidity have fallen markedly. Late complications such as adhesive small-bowel obstruction and retroperitoneal fibrosis with ureteral stenosis are well described, but data on the incidence of these long-term sequelae are still not available.

Peritonitis in the newborn--current concepts

The author provides well-detailed discussion of peritonitis in the newborn and draws the following conclusions. Prognosis for neonates with gastrointestinal perforation has considerably improved and will continue to improve. Sepsis remains the primary cause of death, with necrotizing enterocolitis the most common cause of perforation. The characteristic gastrointestinal microflora and innate immunologic deficiency of this population, particularly in the critically ill preterm neonate, require further delineation.

Barium peritonitis. Report of a case and review of the literature

A case of generalized peritonitis, secondary to a perforation of the rectosigmoid colon during barium-enema roentgenography, is presented. The patient required immediate surgical intervention with the prime importance of the treatment being removal of as much of the contaminating materials as possible. This was done successfully with irrigation and wiping, using urokinase solution. Peritoneal lavage with urokinase solution was also carried out in the early postoperative period. Fluid replacement with careful monitoring of fluid and electrolyte balance is essential before, during, and after the surgical procedure. Adequate antibiotic therapy and careful respiratory and nutritional support are also important.

Hydrostatic reduction of childhood intussusception. The role of adjuvant glucagon medication

The value of glucagon to facilitate hydrostatic reduction of childhood ileo-colic intussusception was tested in a series of 188 consecutive cases. Sixty-nine patients selected at random received 0.05 mg glucagon/kg body weight intramuscularly before attempts at reduction were started. The rate of successfully accomplished reductions was 84 per cent in the test group and 76 per cent in the control group (not significant). The time for accomplished reduction was approximately equal in the two groups. After 3 unsuccessful attempts at hydrostatic reduction patients in the control group received glucagon. The subsequent attempt at reduction proved successful in slightly more than every second case. No complications occurred. In general, glucagon was not found to improve the rate of employed reductions nor on the time necessary for reduction to take place. The investigation indicated, however, that there may be a limited benefit of adjuvant medication of glucagon. After two unsuccessful barium enemas glucagon administration is therefore recommended before a third attempt at reduction is performed.

Conventional abdominal radiography as a means to rule out ileo-caecal intussusception

The experiences gained with conventional radiographic examinations as a means of excluding childhood ileo-caecal intussusception are presented. According to these, a supplementary barium enema is indicated a) in patients under 6 months of age, b) in patients presenting with scant intestinal gas, c) in patients where the caecum cannot be outlined, d) in patients with a possible mass lesion of the colon, e) in patients with obstruction presumably due to intussusception, and f) in patients with discrepancy between the clinical and radiologic findings (1, 4). In all other patients the barium examination is not used. The key to a successful application of this protocol is a thorough familiarity with the limitations and potentials of the conventional abdominal examination.

Blunt abdominal trauma and hollow viscus injury in children: the diagnostic value of plain radiography

Although blunt abdominal trauma is common in children, the G-I tract is involved only rarely. However, this paper deals with a series of 24 cases in whom a hollow viscus was injured. We present the radiological and operative findings as well as the results of subsequent radiological workup in patients who had no surgery. Contrary to the recent trend which stresses early abdominal CT as critically important for guiding treatment we have retained a more conservative attitude. Our present protocol includes plain radiography frequently combined with sonographic screening of the abdomen. In patients with stable vital signs and when necessary, we follow up with scintigraphy. CT is reserved for complicated cases with obscure clinical manifestations which do not fit the plain radiological findings and also cases running an unexpected course.