The Advisability of Immediate Colonic Irrigation Following a Barium Enema

Abstract

The discovery of the utility of opaque substances as a means of visualizing the alimentary tract roentgenographically has been a cardinal factor in the new impetus in gastro-enterology, which has been evident during the last couple of decades. Nevertheless, its development, routine as its use has now become, has not been unattended by occasional upsetting difficulties, unexpectedly covering the attending physician with confusion. Of far more serious significance, they have threatened the well-being of the patient, at times to the point of terminating life. As with most other important discoveries in medical science, the refinement of the use of roentgenography in gastrointestinal diagnosis has revolved around three problems: (1) the endeavor to find a non-toxic or least toxic opaque medium; (2) the clinical mapping out of contra-indications, and (3) the recognition of possible mishaps, their prophylaxis, and treatment. Toxicity of the Medium.—Bismuth, first used as the opaque medium, in spite of its toxicity, was superseded by non-toxic barium sulphate. I t was then found through clinical mishap and bitter experience that the substitution in itself was insufficient as a safeguard. It was essential that the insoluble barium sulphate used must be free from contamination with soluble and poisonous barium salts. The poisons of this nature most frequently encountered in clinical practice have been barium chloride, barium carbonate, barium sulphid, barium nitrate, and barium acetate. Though accidents with barium salts have been comparatively rare, the number of barium meals and enemas given in roentgen-ray work necessitates that the physician shall attend to the purity of the suspension he utilizes. McNally (1), who reviewed this subject in 1925, cited 44 deaths caused by soluble barium salts poisoning, and reported two additional cases. In one of these latter, the physician had erroneously written “barium carbonate” instead of “barium sulphate” in his prescription. The error was not detected by the pharmacist, and the patient died. In the other case, a woman drank barium sulphid in buttermilk, with fatal result. McNally comments on the fact that the barium sulphate given to patients for roentgen-ray examination should be of a chemically pure grade only, should be administered only by the physician who is to make the examination, and that “each lot of barium sulphate should be tested for soluble barium compounds.” On the score of the confusion of the soluble barium salts with insoluble barium sulphate, the U. S. Pharmacopeia cautions: “In prescribing barium sulphate the title should never be abbreviated, to avoid confusion with the poisonous barium sulphide or sulphite.” It is axiomatic, too, that as imperative a precaution is necessary with regard to the use of a barium sulphate known to be free of these soluble salts.