Early colonic obstruction after barium swallow treated by gastrografin enema

Clinical History

Intestinal obstruction following a barium examination is a rare complication. We report a case of distal large bowel obstruction caused by a large barium plug (barolith), occurring as early as a week after a barium swallow. This was successfully treated with a gastrografin enema.

Imaging Findings

A 70-year-old man with lower oesophageal cancer underwent a barium swallow, which showed an irregular stricture at the gastro-oesophageal junction. Subsequently, an upper gastrointestinal endoscopy with biopsies confirmed this to be an oesophageal adenocarcinoma. A week later, whilst admitted for a diagnostic work-up, he developed signs and symptoms of complete large bowel obstruction. A scheduled upper abdominal and chest CT scan with contrast was carried out on the day of him developing the obstruction. This revealed an obstructing lesion (large barium plug- barolith) at the level of the mid-distal descending colon with proximal colonic and small bowel dilatation (Figure 1 and 2). A subsequent plain X-ray confirmed these findings. He was conservatively managed overnight and a gastrografin enema was performed the following morning to assess if this was radiologically a complete obstruction. This showed free passage of contrast to the level of the barolith in the distal descending colon, with a small amount of contrast managing to pass proximally into the dilated colon, suggesting it was a near complete obstruction (Figure 3). Distal to the barolith there appeared to be narrowing of the colon and the examination could not differentiate between a bowel spasm and stricture. Hours after the gastrografin enema, he successfully decompressed his bowel. A follow-up plain abdominal x-ray showed no evidence of the barolith and the bowel loops were less dilated. A flexible sigmoidoscopy was performed prior to his discharge in light of the gastrografin enema report but this showed no evidence of a stricture or mucosal lesion.

Discussion

All documented case reports^1-3 of barolith obstruction have shown a delayed presentation by many months or years after the examination. However our patient developed obstruction as early as a week after his barium swallow. Considering the study by Borden⁴, in which 57% of patients cleared barium from the colon within a week of a barium study and by 4 weeks in the remainder, it remains theoretically possible for an early obstruction to occur. The risk factors for barolith formation include advanced age (as in our case report), low-residue diet, dehydration, poor colonic motility and colonic stenosis². Barium has the potential to cause obstruction, as it is a highly insoluble material and must be finely pulverised and mixed with dispersing agents to allow suspension in water⁵. If patient’s bowels are sluggish they can become pre-disposed to excessive water re-absorption and inspissation of the barium, which could subsequently lead to intestinal obstruction. Various non-operative options on the successful dissolution of uncomplicated baroliths have been reported in the literature. These have included lactulose⁶, oral gastrografin⁷, and colonoscopic lavage⁸. The therapeutic option of gastrografin enema in the treatment of this condition has not been previously reported. In our case, this successfully decompressed the large bowel within 4 hours, suggesting significant fluid shift into the bowel lumen and possible rehydration and breakdown of the barium plug. The combination of these factors had allowed the passage of the obstructing barium material without the need for either a surgical intervention or a colonoscopic lavage. In this particular case, a laparotomy would have delayed his definitive treatment for the oesophageal cancer. The advantage of using gastrografin apart from its therapeutic role is to assess if there are any constricting lesions in the bowel distal to the barium plug. If this proves to be the case then surgical treatment would become necessary and the pathology could be tackled at the same time. Our report illustrates that gastrografin can be used in patients with barolith obstruction, provided there are no clinical signs to suggest peritonitis, where a laparotomy would be necessary. It is recognised that barolith obstruction is a rare event and our report suggests that it can occur as early as 1 week after the procedure. In addition, gastrografin enema has been found to be successful in the treatment of this condition.

Differential Diagnosis List

Final Diagnosis

A rare case of barolith obstruction treated by gastrografin enema.

URL:	https://www.eurorad.org/case/6333
DOI:	10.1594/EURORAD/CASE.6333
ISSN:	1563-4086