A Case of Barium Inspissation Resulting in Acute Constipation and Colectomy

Abstract

Introduction: Barium sulfate is an insoluble salt commonly used in radiologic studies. It is generally considered a low-risk contrast medium with the most common complications including abdominal cramping, nausea, vomiting, and constipation. However, rarely, severe complications can occur including viscus perforation, barium inspissation, embolization, aspiration, and poisoning secondary to barium intravasation. These complications are important to recognize and often require drastic endoscopic and surgical measures. Case Report: An 86-year-old female with history of refractory peptic ulcer disease requiring previous Bilroth II surgery later complicated by gastric outlet stenosis resulting in placements of gastrostomy and jejunostomy tubes was admitted for intractable bilious vomiting and septic pneumonia. Patient reported diffuse abdominal pain and was uncertain of the timing of her last bowel movement. Symptoms started after a barium swallow study 1 week prior to presentation. Physical exam was notable for tachycardia, hypotension, and distended tender abdomen with minimal bowel sounds throughout. Her labs revealed a hemoglobin 8.2 g/dL, WBC 12.2 x 1000, creatinine 1.6 mg/dL, and lactate 2.6 mmol/L. CT of her abdomen showed diffuse colonic and distal small bowel dilatation with excessive amounts of intraluminal stool and inspissated barium solution. Patient required support with vasopressors and was treated with antibiotics. Polyethylene glycol, sodium polystyrene sulfonate, lactulose enemas, tap water enemas, mineral oil, manual disimpaction, and sigmoidoscopy were unsuccessful at disimpacting the colon. The patient subsequently underwent total colectomy 6 days into hospital stay with end-ileostomy and was discharged in stable condition. Discussion: Barium impaction is a rare complication of barium studies with 1 review reporting 31 reported cases between 1950 and 2006. However, it is associated with significant morbidity as nearly half of the reported cases required surgical intervention. Risk factors for barium inspissation are any changes to intestinal anatomy or intraluminal diameter and any medical conditions or drugs affecting colon motility. Prevention with proper hydration and administration of laxatives following barium studies is recommended in those at increased risk.