A Marshmallow Cast

Abstract

Appendicolith is a mixture of firm heces with some mineral deposits and also a frequent cause of obstruction of the appendiceal lumen that results in appendicitis. Furthermore, Barolith is the term given to an appendicolith composed of barium sulfate, which is a contrast media broadly used for gastrointestinal imaging. Nonetheless, some complications like aspiration, allergic reaction, bowel obstruction and appendicitis have been reported. For instance, as identified in a nationwide study, there is an increased, time-dependent risk of appendicitis in patients who undergo barium study. On the other hand, barium peritonitis, as result of perforation, is a rare complication seen in contrast enema studies. Finally, barolith causing intestinal obstruction can occur approximately 5 weeks after barium exam and is most commonly found on the left colon. Interestingly, this can be medically managed with laxatives and/or colonoscopic dissolution. We present a 71 year old man with a history of ALS comes to the gastroenterology clinic complaining of intermittent loose stools and dysphagia to solids for the past months, who received treatment with bentyl and loperamide. Patient comes to the GI clinic for a scheduled colonoscopy as part of the workup, who got a barium swallow study 6 days earlier. The procedure was done showing normal appearing mucosa, with a whitish foreign object found on the appendiceal orifice. Removal of the barolith was done by means of a biopsy forceps. Patient was sent home with a scheduled appointment. Fortunately, our patient did not have any signs or symptoms of appendicitis prior to the procedure, and a successful removal of the barolith was achieved. Elderly patients and patients with decreased GI transit could be a population at risk for barium retention/appendicitis, for this reason more studies should be done in order to assess for possible preventive treatments. The purpose of this case report is to increase awareness of potential GI complications after barium studies in order to increase prompt diagnosis.Figure: Barium cast emerging from appendiceal orifice.Figure: Extracting barolith.Figure: Barolith extracted.