Barium Impaction: A Rare Cause of Bowel Obstruction

Abstract

Barium enema is a special x-ray of the colon and rectum. Barium is not water soluble and becomes inspissated in the colon when water is absorbed. Rarely, the thickened barium can cause an obstruction in the gastrointestinal tract. In most cases medical management will not suffice and endoscopic or surgical intervention is required to ameliorate the obstruction. We report a case of barium impaction of the cecum that occurred sixteen days after a barium enema but more interestingly two days following bowel surgery for an ileostomy reversal. The obstruction resolved without endoscopic or surgical intervention but rather conservative management alone. A 36-year-old male with no significant medical history was admitted for sigmoid diverticulitis that was complicated by perforation. Exploratory laparotomy with sigmoid resection and primary anastomosis with a loop ileostomy was performed. Six weeks later a diagnostic colonoscopy was performed prior to the reversal of the ileostomy. The procedure was aborted secondary to an incomplete bowel preparation. The patient refused a second colonoscopy so a barium enema was performed which revealed a patent sigmoid anastomosis. Fourteen days later the patient was taken for surgery to reverse the loop ileostomy. On postoperative day 2 the patient complained of intermittent, crampy abdominal pain, nausea, and vomiting. The patient was febrile but vital signs were otherwise unremarkable. Physical examination revealed a tender, distended abdomen that was tympanic with hyperactive bowel sound. Laboratory studies revealed a leukocytosis and hypokalemia. X-ray of the abdomen (see Image 1) and computed tomography of the abdomen and pelvis displayed a 7.0 centimeter barium concretion in the cecum causing obstruction of the colon with dilated loops of small bowel. Emergent colonoscopy with removal of the barium was not performed for concern of perforation. The patient was treated conservatively with laxatives and tap water enemas in an effort to loosen the concretion. Two days later the patient defecated the barium and a repeat abdominal radiograph showed resolution of the obstruction. Barium impaction is a rare complication and cecal impaction is exceedingly rare. Although it has been historically described in other parts of the colon there are only three reported cases of barium impaction in the cecum. This may be due to the wider diameter of the cecum. What makes our case even more interesting is that the obstruction presented greater than two weeks after the Barium enema and two days after bowel surgery for the ileostomy reversal. We believe that a post-operative ileus likely contributed to the impaction and that in these cases conservative bowel preparations alone may lead to resolution of the obstruction.Figure 1