Barium Sulfate in Saline Suspension

Abstract

There is a small group of patients with symptoms of unexplained rectal bleeding or abdominal tumor who present an unusually difficult diagnostic problem to the roentgenologist. These patients fall into two categories: (1) The patient who cannot retain an enema because of a relaxed or damaged anal sphincter or perineum. Some of these patients will expel even a rectal tip surrounded by an inflated rubber balloon, and since the usual oral barium sulfate mixture becomes rapidly dehydrated in the colon, it is of little value in outlining anatomical lesions. (2) Patients who do not have clinical obstruction or dilatation of the intestine but who present complete obstruction to the retrograde passage of a barium enema. It is with this group of patients that the present paper is primarily concerned. Many of these patients have diverticulitis, and a small percentage also have rectal bleeding due to the diverticulitis. The incidence of carcinoma in the age group in which such patients fall is, however, so high that every effort must be made to exclude a source of bleeding other than the diverticula. The oral administration of barium sulfate has long been considered dangerous in the presence of any obstruction of the descending or sigmoid colon because of the probability of dehydration and impaction of barium-containing feces proximal to the obstruction. It is well known that barium sulfate administered orally is frequently passed with difficulty even by normal patients. If, however, dehydration of the barium mixture can be prevented, it is no more likely to cause impaction and obstruction than normal feces. One logical method of preventing dehydration of the barium in the left colon is to administer it with a saline cathartic which, by its very nature, maintains and increases liquefaction of the contents of the colon. This method has been employed as follows: (1) The patient, if not already in the hospital, is hospitalized. (2) Four ounces of barium sulfate powder, i.e., half a tumblerful, is mixed with 8 oz. of magnesium citrate (liquor magnesii citratis, U. S. Pharmacopeia, Vol. 13, p. 294). This mixture is administered orally early in the morning and the patient is allowed water ad lib. Another 8 oz. of magnesium citrate, without additional barium, is given about an hour and a half later, and fluoroscopy is then done at intervals starting about two hours following the administration of the barium. The speed of passage of the barium-saline mixture varies markedly with the degree of obstruction and the age and physical activity of the patient. Excretion is usually almost complete at the end of eighteen hours or earlier. Such patients must obviously be kept under roentgenologic observation until the barium is excreted and should be kept in the hospital for facilitation of such observation. Many clinicians are justifiably opposed to the administration of either barium enemas or cathartics to patients with diverticulitis.