Barium enema perforation- Conservative management of two cases.

Salim Kurrimboccus, R Elati, V Velineni, Chui.
Alexandra Hospital, Redditch, Worcestershire, U.K.

We report two cases of perforation during barium enema, both successfully managed conservatively. This is an uncommon but significant complication with very high morbidity and mortality if there is delay in diagnosis and treatment. Our report demonstrate that, with careful patient selection, some patients can managed non-operatively.

Key words: Barium enema, perforation, management.

INTRODUCTION

Perforation of the colon or rectum is a serious complication of the barium enema examination, occurring in 0.02% to 0.04% of patients. (1) Intraperitoneal perforation is especially devastating, due to the combination by barium and bacterially loaded faecal material within the peritoneal cavity. This causes an intense peritoneal inflammatory reaction leading to intravascular volume depletion, tachycardia, hypotension and shock. Fortunately, extraperitoneal perforation is usually less catastrophic. We report two cases of barium enema perforation successfully treated conservatively.

CASE REPORT 1

A 70-year-old male electrician was referred by his General Practitioner to the Gastroenterology department with a two month history of flatulence. His past medical history included non-insulin dependent diabetes mellitus on Metformin and drug-controlled hypertension. He had a family history of colonic carcinoma, his mother and maternal uncle having developed the disease in their seventies.

Clinical examination was unremarkable. A barium enema was performed. During the procedure, barium was found to extravasate from the region of the sigmoid colon and the patient was referred immediately to the on-call surgical team. On examination, the patient was pain-free, afebrile and haemodynamically stable. Abdominal examination revealed a soft non-tender abdomen. Review of barium enema films with the Consultant Radiologist showed extravasation of barium into the sigmoid mesocolon in the mid-sigmoid region (Figure 1) without any evidence of underlying disease. All the blood tests were normal. A chest x-ray did not reveal any pneumoperitoneum. Immediate fluid resuscitation and intravenous antibiotics were initiated. Since the patient was completely asymptomatic and stable, the decision was made to attempt conservative management. He was kept under close observation. A nasogastric tube was passed and he was initially kept on nil orally. He remained totally asymptomatic and was subsequently discharged home six days later. He had a colonoscopy three months later, which revealed 3 sessile polyps in the rectum, all of which were excised. The rest of the visualized bowel was normal.

Figure 1

CASE REPORT 2

A 77-year-old female patient was referred by her General practitioner in July 2002 to the surgical outpatient department with a two month history of change in bowel habit associated with colicky lower abdominal pain and recent weight loss.

On clinical examination there was the suspicion of a mass in the left hypochondrium. An urgent barium enema was requested. During the procedure, the patient collapsed and became unconscious. A focal left arm seizure was witnessed for a one minute duration and she slowly regained consciousness and fully recovered. She was seen by the on-call medical team who, after clinical examination, thought she had suffered a vasovagal event. However, a chest x-ray revealed gas under diaphragm and the patient was then referred to on-call surgical team. On examination, she was not in any pain, was afebrile and haemodynamically stable. Her abdomen was distended but perfectly soft. There was deep tenderness in the hypogastrium. Review of barium enema images revealed localized air outside the lumen of the right colon, hepatic flexure and caecum from a localized perforation in the right colon. The appearances of the colon otherwise were of a chronic colitic process such as ulcerative colitis.

In view of the patient being asymptomatic without any clinical signs of peritonitis, she was managed conservatively with intravenous rehydration and antibiotics. She remained well and subsequently discharged home a week later.

DISCUSSION

Evidence exists to support that a non-operative approach is safe in small extra-peritoneal injuries in asymptomatic patients. (2) Our first patient had extravasation of barium in the sigmoid mesocolon and responded favourably to non-surgical treatment. More extensive, extraperitoneal extravasation, if not immediately treated, may cause a peri-rectal tissue infection and lead to fatal septicaemic shock within a few hours or days. Less extensive contamination may lead to pelvic sclerosis with later development of rectal and ureteric stenosis. Unfavorable factors are extensive extravasation of barium, delay in diagnosis, presence of faeces in the rectum and inadequate preparation of the patient.(3) However free intraperitoneal rupture can rapidly give rise to a hypotensive state which can prove fatal. Adequate resuscitation and early resection or primary repair and an aggressive effort to evacuate as much barium as possible are mandatory. Radiologists should initiate fluids without delay upon recognizing perforation.(4) Asymptomatic perforation, causing only air extravasation, responds favorably to bowel rest, fluids and antibiotics.(5) The caecum and ascending colon are more likely to perforate in view of their lower bursting pressures. This was the case in our second patient.

Tadros and Watters (6) suggested four mechanisms of injury :

1) trauma from the enema tip

2) overinflation of the balloon

3) recent colonoscopic instrumentation especially associated with biopsy

4) the presence of rectal mucosal disease such as cancer, stricture, diverticulosis or inflammatory bowel disease.

To limit the risks of perforation, it is suggested that in all cases, a sigmoidoscopic examination should be performed prior to barium enema radiography to assess the status of the rectum. A safe tip-balloon design should be used and inserted by a physician after a careful digital rectal examination. A retention balloon should be inflated only under fluoroscopic monitoring. Barium studies should be avoided in patients with active colitis. In cases of deep biopsy or polypectomy, the examination should be delayed by at least six days. Finally, generation of pressure greater than that created by a column of barium suspension of one meter should be avoided. (1)

CONCLUSION

In conclusion, barium enema is a safe and accurate diagnostic study of the colon and rectum but serious complications can occur of which perforation is the most common. When this does happen, management cannot be rigidly prescribed and should be instituted case by case dependent on the nature and extent of contamination. Asymptomatic patients with extravasation of air only or with minor extraperitoneal barium leakage and no intraperitoneal soiling, can be treated conservatively with intravenous fluids, broad-spectrum antibiotics and close clinical monitoring.

REFERENCES

1. Williams S and Harned R. Recognition and prevention of barium enema perforations. Curr Probl Diagn Radiol 1991 Jul-Aug;20 (4): 121-151

2. Thomson SR, Fraser M, Stupp C et al. Iatrogenic and accidental colon injuries-What to do?. Dis Colon Rectum 1994; 37: 496-502

3. Terranova O, Meneghello A, Battocchio F et al. Perforations of the extraperitoneal rectum during barium enema. Int Surg 1989; 74: 13-16

4. Han SY and Tishler JM. Perforation of the colon above the peritoneal reflection during the barium enema examination. Radiol 1982; 144: 253-255

5. Wang TK and Tu H. Colorectal perforation with barium enema in the elderly: case analysis with the POSSUM scoring system. J Gastroenterol 1998; 33:201-205

6. Tadros S and Watters JM. Retroperitoneal perforation of the rectum during barium enema examination. Can J Surg 1988 Jan; 31(1):49-50