Retroperitoneal barytoma

Vaginal laceration during barium enema with extraperitoneal extravasation: Case report and literature review

Unrecognized vaginal intubation during the barium enema procedure with subsequent balloon inflation and contrast instillation is a potentially fatal complication of an otherwise common and routine procedure. We describe a patient who, while undergoing a routine barium enema, had misplacement of the enema catheter into the vagina, subsequent rupture of the superior/lateral vagina upon inflation of the catheter retention balloon, and injection of barium contrast into the retroperitoneum. The patient was admitted for surgical repair of the vaginal laceration and monitoring for chemical peritonitis; and was managed without exploratory laparotomy. We review the existing literature, summarize 18 reported cases from worldwide literature, detail potential complications and propose management and prevention strategies based on the mechanism of injury.

Proper management for morbid iatrogenic retroperitoneal barium insufflation

A barium enema is a diagnostic and therapeutic procedure commonly used for colon and rectum problems. Rectal perforation with extensive intra- and/or extraperitoneal spillage of barium is a devastating complication of a barium enema that leads to a significant increase in patient mortality. Due to the low number of reported cases in recent scientific literature and the lack of experience with the management of these cases, we would like to present our treatment approach to a rare case of retroperitoneal contamination with barium, followed by its intraperitoneal involvement during a diagnostic barium enema. Our experience with long-term management of the patient and the good outcome will be depicted in this paper.

[Retroperitoneal fibrosis due to Schistosoma japonicum: a case report]

We report a case of retroperitoneal fibrosis due to Schistosoma Japonicum in patient with urothelial carcinoma. Retroperitoneal fibrosis was observed in a-83-year-old man during examinations for postrenal renal failure. The symptoms were improved by percutaneous nephrostomy and pulse therapy using corticosteroids, however, urothelial carcinoma was detected during follow-up examinations. The biopsy of retroperitoneal tissue was performed during the surgery for urothelial carcinoma. The histopathological examination revealed scattered calcified eggs of Schistosoma Japonicum in retroperitoneal fibrosis tissue. Therefore, in this case, we assumed Schistosoma Japonicum was the cause of retroperitoneal fibrosis. In our knowledge, there is no report about retroperitoneal fibrosis due to Schistosoma Japonicum. We hypothesize the pathway that the eggs penetrate into retroperitoneal space is extravasation from intestinal wall and peritoneal cavity, although the detail of this mechanism is not obvious. It is well known about the relationship between Schistosomasis and malignant tumors. However, it seemed no evidence regarding the relationship between Schistosoma Japonicum and urothelial carcinoma, since there is no report about it and the eggs were not found in specimen of urothelial carcinoma.

Rectal perforations after barium enema: a review

PURPOSE

Rectal injuries during barium enema are rare but life-threatening complications. The last review about this subject was published more than ten years ago. In the present review, we present an overview on the subject and especially focus on changes in treatment strategies and developments of less risky visualization techniques.

METHODS

A literature search was performed in the PubMed library using the key words-barium enema, complications, peritonitis, and rectal perforation-as well as related articles and other references obtained from these articles.

RESULTS

The most frequent cause of perforation is iatrogenic and catheter-related. Other causes are related to weakness of the colorectal wall or obstruction. Five types of perforations have been described: 1) perforations of the anal canal below the levator; 2) incomplete perforations; 3) perforations into the retroperitoneum; 4) transmural perforations into adjacent viscera; 5) perforations into the free intraperitoneal cavity. Most incomplete perforations and one-half of the retroperitoneal perforations have minimal clinical signs. Intraperitoneal perforations lead to the most catastrophic course, starting with rectal bleeding and mild abdominal complaints. This is rapidly followed by progressive sepsis and peritonitis, and leads to a high mortality rate. Surgery is not always required for intramural or small retroperitoneal perforations. These can be treated conservatively and require surgical debridement only in case of large amounts of extravasation or abscesses. Surgical repair of large rectal mucosal lesions or anal sphincter lesions is advised. Perirectal abscesses require drainage. Intraperitoneal perforations with gross extravasation need immediate aggressive surgical treatment in a critical care setting, because the threat of shock is high. Intraperitoneal perforations, neglected perforations, gross barium extravasation, poorly prepared colon, and venous intravasation of barium are prognostically unfavorable. The severest late complication in intraperitoneal perforations is ileus. Meticulous technical performance of the barium enema is the most important factor in prevention.

CONCLUSIONS

Rectal perforations after barium enema are rare. The overall mortality rate decreased in recent decades from approximately 50 to 35 percent as the result of advances in supportive and intensive care. Because of these advances, more aggressive surgical strategies were undertaken. With the advent of endoscopy, less barium enemas are performed. Consequently, the absolute incidence of complications has decreased. It is expected that in the future barium enemas will be replaced by more sensitive and less risky techniques, such as CT colonography and magnetic resonance colonography.

Complications from inflation of a retention rectal balloon catheter in the vagina at barium enema

We describe two complications arising from the inadvertent introduction and inflation of a retention rectal balloon catheter in the vagina. Barium entered the uterus, fallopian tubes and peritoneal cavity in one and caused a forniceal tear and venous intravasation in the other. In both cases the catheter misplacement was attributed to atrophy of the perineal body. Various recommendations have been made to reduce the risks associated with the use of balloon catheters but we wish to emphasize the importance of a digital rectal examination to define the perineal anatomy and the use of a gloved finger to guide the balloon catheter into the rectum.

Complications of barium enema examinations: a survey of UK Consultant Radiologists 1992 to 1994

Questionnaires were sent to all Consultant Radiologists in the UK regarding complications from barium enema examinations. The 756 respondents performed a total of 738,216 examinations over the three year period 1992 to 1994. Seventy-seven Consultants (10.2%) reported a total of 82 complications including 13 deaths: an overall mortality rate of 1 in 56,786. Only three of 30 (10%) cases of bowel perforation died, as compared with nine out of 16 (56%) cases of cardiac arrhythmia. The only remaining death was a consequence of vaginal intubation. Details of all the reported complications are recorded. This was an entirely retrospective study.

Recognition and prevention of barium enema complications

The barium enema is a safe and accurate diagnostic study of the colon but, in rare cases, complications may result. Many of these can be prevented by proper equipment and careful attention to technique. When a complication does occur, prompt recognition and management is vital in decreasing morbidity and mortality. Perforation of the bowel is the most frequent serious complication, occurring in approximately 0.02% to 0.04% of patients. Rarely the colon may burst due to excessive transmural pressure alone. However, a colon weakened by iatrogenic trauma or disease is more likely to perforate during an enema than is a normal healthy bowel. Injury to the rectal mucosa or anal canal due to the enema tip or retention balloon is probably the most common traumatic cause of barium enema perforation. Inflation of a retention balloon within a stricture, neoplasm, inflamed rectum, or colostomy stoma is particularly hazardous. Recent deep biopsy or polypectomy with electrocautery makes the bowel more vulnerable to rupture. The tensile strength of the bowel wall is impaired in elderly patients, patients receiving long-term steroid therapy, and in disease states including neoplasm, diverticulitis, inflammatory bowel disease, and ischemia. Intraperitoneal perforation leads to a severe, acute peritonitis with intravascular volume depletion. The ensuing shock may be rapidly fatal. Prompt fluid replacement and laparotomy are essential. If the patient survives the initial shock and sepsis, later complications caused by dense intraperitoneal adhesions may develop. Extraperitoneal perforation is usually less catastrophic but may result in pain, sepsis, cellulitis, abscess, rectal stricture, or fistula. Intramural extravasation often forms a persistent submucosal barium granuloma which may ulcerate or be mistaken for a neoplasm. The most dramatic complication of barium enema is venous intravasation of barium. Fortunately, this is quite rare as it may be immediately lethal. Most cases have been attributed to trauma from the enema tip or retention balloon, mucosal inflammation, or misplacement of the tip in the vagina. Bacteremia has been found in as many as 23% of patients following barium enema and, in rare cases, may cause symptomatic septicemia. Other less common complications include barium impaction, water intoxication, allergic reactions, and cardiac arrhythmias. Preparatory laxatives and cleansing enemas have been implicated in some instances of dehydration, rectal trauma, water intoxication, and perforation. Careful review of the indications for examination, previous radiographs, and clinical history will identify many of the patients at greater risk for complications so that appropriate precautions may be observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Perforation of the rectum and sigmoid colon during barium-enema examination. Management and prevention

Perforation of the rectum or sigmoid colon complicated 5 of 2200 barium-enema examinations performed during a 4-year period. Three patients with rectal perforations manifested by air extravasation were successfully treated with intravenous antibiotics and complete bowel rest. Two patients with barium extravasation were treated with immediate operation and colostomy. All five patients recovered. Perforation was found to be associated with a rectal stricture due to ulcerative colitis, a rectal cancer, an incarcerated inguinal hernia, fulminant ulcerative colitis, and a normal colon in an elderly patient. To determine the pressure in the rectum that could potentially be generated during a barium-enema examination, the pressures created by a standard barium delivery set were measured, using 1-meter columns of water, 25 percent diatrizoate sodium (Hypaque), 20 percent barium, and 80 percent barium. The columns generated pressures of 70, 85, 95, and 120 mm Hg respectively. Squeezing the delivery bag increased the pressure 21 to 79 percent or a maximum of 55 mm Hg. Colorectal perforation during barium-enema examination that was not accompanied by barium extravasation could be successfully treated nonoperatively. The associated pathology and our studies of pressures generated during a barium-enema examination allow us to suggest that the incidence of colorectal perforation during barium-enema radiography can be reduced by 1) performing proctoscopy prior to barium enema, 2) avoiding the use of the rectal balloon in patients with known rectal lesions, 3) avoiding barium studies in patients with active colitis, 4) avoiding generation of pressure greater than that created by a column of barium suspension of one meter, and 5) using a lower concentration of barium when possible.

Rectal perforation during barium enema. Report of a case

Perforation of the colon or rectum during the course of barium-enema examination is estimated to occur in approximately 500 patients annually in the United States. It has been over 30 years since the last collective review on this subject reported a prohibitively high mortality and morbidity. Since that time, much has been learned about the treatment of patients with peritonitis and bowel perforation, many new and more effective antibiotics have become available, and the management of shock has become infinitely more sophisticated. A review of recently reported cases suggests that the mortality rate and possibly the early morbidity have fallen markedly. Late complications such as adhesive small-bowel obstruction and retroperitoneal fibrosis with ureteral stenosis are well described, but data on the incidence of these long-term sequelae are still not available.