A Rare Complication of Barium Swallow Test

Abstract

Question: A 70-year-old man with gastroenteropancreatic neuroendocrine tumor of the duodenum underwent robotic subtotal stomach-preserving pancreatoduodenectomy (PD). During the surgery, retrocolic reconstruction for pancreaticojejunostomy and hepaticojejunostomy, as well as antecolic reconstruction for gastrojejunostomy, were performed. Surgical anatomy following these reconstructions is illustrated in Figure A. The patient’s postoperative follow-up was uneventful. Six months later, the patient underwent a barium swallow test for a medical checkup at another hospital. The examination found no significant findings in the stomach, but revealed reflux of the barium sulfate into the intrahepatic biliary trees through the afferent loop (Figure B). After the barium swallow test on that day, the patient was referred to our hospital. He complained only of fever, but did not demonstrate other symptoms. The laboratory findings showed the following unremarkable changes: white blood cell, 6920/μL; total bilirubin, 0.89 mg/dL; direct bilirubin, 0.25 mg/dL; aspartate transaminase 23 U/L; alanine aminotransferase, 22 U/L; and C-reactive protein, 0.76 mg/dL. The abdominal computed tomography revealed retained barium sulfate in the bilateral biliary system (Figure C). What is the treatment strategy for this patient? Look on page 402 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Retained barium sulfate in the biliary system may cause hepatolithiasis because of progressive water absorption, leading to complications such as obstructive jaundice, cholangitis, and sepsis.1Walsham A. Larsen J. Adverse effects of barium sulfate in the biliary tract.Diagn Interv Radiol. 2008; 14: 94-96PubMed Google Scholar Despite the absence of guidelines for the treatment of barium-induced choleliths, evidence-based guidelines for hepatolithiasis after biliary reconstruction propose peroral endoscopic treatment as the first-line option, or percutaneous transhepatic biliary drainage (PTBD) as an alternative.2Tazuma S. Unno M. Igarashi Y. et al.Evidence-based clinical practice guidelines for cholelithiasis 2016.J Gastroenterol. 2017; 52: 276-300Crossref PubMed Scopus (71) Google Scholar However, endoscopic approaches using a double-balloon endoscope (DBE) could be less invasive and have several advantages in bilateral drainage as well as in the accurate evaluation for residual choleliths with peroral direct cholangioscopy.3Ishihara Y. Matsumoto K. Kato H. et al.Treatment outcomes, including risk factors of stone recurrence, for hepatolithiasis using balloon-assisted endoscopy in patients with hepaticojejunostomy (with video).Surg Endosc. 2020; 34: 1895-1902Google Scholar Therefore, urgent endoscopic intervention was attempted in this case. In facilities where DBEs are not available, PTBD should be considered. Using DBE, saline was injected into the biliary trees via a catheter through the hepaticojejunostomy, and barium sulfate lodged at the main bile duct was washed out (Figure D). An endoscopic nasobiliary drainage tube was placed, and further irrigation was conducted for 3 days. After confirmation of duct clearance by a computed tomography scan, the patient was discharged. The reflux of orally administered barium sulfate into the intrahepatic biliary system is a rare but complicated adverse effect of a barium swallow test. To date, several conditions, including spontaneous or postoperative fistula and choledochoenterostomy, have been reported to be associated with reflux.1Walsham A. Larsen J. Adverse effects of barium sulfate in the biliary tract.Diagn Interv Radiol. 2008; 14: 94-96PubMed Google Scholar However, to our knowledge, this report is the first of barium sulfate reflux into the intrahepatic biliary trees in a patient undergoing PD. Urgent endoscopic intervention was safe and effective to prevent barium-induced biliary complications. In conclusion, the present case demonstrated a rare complication of barium sulfate in the biliary system following biliary reconstruction. It suggests that barium swallow test following PD should be contraindicated. Therefore, in similar patients experiencing this rare adverse effect, urgent intervention with DBE or PTBD should be performed to avoid complex biliary complications.