Gastrointestinal: Barium‐induced acute appendicitis

Abstract

A 48-year-old woman was admitted to hospital with fever and pain in the right lower quadrant of her abdomen. Eight hours previously, she had been investigated with a barium study that was performed through an ileostomy stoma. She had previously been diagnosed with rectal cancer and had been treated by a low anterior resection with a protective ileostomy. The barium study was performed to confirm the absence of extravasation of barium at the rectal anastomosis. On examination, she had a temperature of 38.5°C and had tenderness and rebound tenderness over McBurney's point. Blood tests revealed an elevated white cell count with a toxic left shift. A supine plain abdominal radiograph revealed retained barium in the cecum and in the appendix (arrow, Fig. 1). The presence of barium in the appendix was confirmed by a computed tomography scan and, in addition, there was mild swelling of the appendiceal wall. The patient was diagnosed with appendicitis and had an urgent appendectomy. The resected specimen was red and edematous and contained barium within the appendiceal lumen (Fig. 2). There were no post-operative complications. “Barium appendicitis” appears to be rare as there are only a small number of case reports in the medical literature. Presumably, the administration of barium results in obstruction of the lumen of the appendix, either by barium alone or by barium mixed with fecal material. The development of appendicitis may also be facilitated by luminal narrowing of the appendix by lymphoid hyperplasia or other disorders. Whether barium results in chemical irritation of the appendix remains unclear. In the patient described above, an additional mechanism might be the generation of high pressures in the appendix by the administration of barium through an ileostomy rather than through the rectum. In case reports, the interval between the administration of barium and the development of appendicitis has ranged from hours (as above) to weeks or months. In the latter settings, barium presumably impregnates the fecal material that subsequently results in appendicitis. Whether prolonged retention of barium is rare or common remains unclear (as follow-up radiographs are rarely performed). However, reports have raised the possibility that “barium appendicitis” is associated with a higher frequency of complications such as perforation than “idiopathic” appendicitis. Contributed by