CASE REPORT I Barium peritonitis with barium entering the lymphatic system s. Andronikou FC Rad Diag (SA) C. Weiman MBChB E. Kader MBChB Department of Paediatric Radiology, university of Cape Townand Institute of Child Health, Red Cross w.v Mernori8J Children's ~ital, Rondebosch, Cape Town Corresponding author S. Andronikou Department of Paediatric Radiology Red Cross War Memorial Children's Hospital Cape Town 7700 TeiepilOne: 021-6585442 Fax: 021-6585101 E-mail: docsav@mweb.co.za Abstract Barium is still widely used in developing countries for gastrointestinal investigation because it is cheap and relatively safe. Most institutions however favour low-osmolar non-ionic contrast media for performance of childhood diagnostic enemas. These are relatively expensive and many developing countries reserve their use for cases where perforation is suspected. We present a case where bari um leaked into the peritoneum during an enema investigation where no initial features of perforation were present. The added unique campi ication of barium entering the 14 SAJOURNAL OF RADIOLOGY· August 2000 thoracic lymphatic system was noted. This campi ication was not found in a review of current literature. Key words Barium enema, low- osmolar non-ionic contrast media, campi ications. Case report A lO-day-old neonate was deliv- ered prematurely at 29 weeks gesta- tion weighing 1 060 grams. He was referred to the radiology department for a barium enema examination with the diagnosis of small bowel atresia. The clinical evaluation revealed ab- dominal distention and plain film ra- diology showed proximally dilated small bowel with absent distal gas. No features of bowel perforation were present on this series. The objective of the study was to demonstrate any co-existing colonic strictures as these are difficult to assess at laparotomy. Barium is still used as a contrast me- dium for enemas, when no bowel per- foration is suspected, in countries where there are cost constraints on the use of low-osmolar non-ionic agents. The examination showed no colonic strictures, but barium flowed freely into the peritoneal cavity from the ileocaecal junction. The patient was taken immediately to laparotomy. The surgeon found a necrotic terminal il- eum and a large amount of free barium in the peritoneal cavity. Small bowel resection and re-anastomosis was performed and vigorous perito- neal washout was undertaken. Subse- quent chest and abdominal radio- graphs (Figures 1 and 2) demonstrated to page 16 mailto:docsav@mweb.co.za Bariun. peritonitis vvith barium entering the lymphatic system 'rom page 14 Figure 1: Post-operative anterior-posterior chest radiograph demonstrates barium coating the peritoneal surface and located as several foci along the left sternal border (arrowheads). Figure 2: Post-operative lateral chest radiograph confirms the retrosternal position of the barium (arrowheads) in keeping with its drainage via the internal thoracic lymphatic chain. barium tracking along the retrosternal part of the chest and at the thoracic duct. This represented barium entry into the internal thoracic chain of lymph nodes. At the time of this report the patient's condition was stable. Discussion ture, 500 perforations during barium enema examination have been reported in a year, but these figures were obtained over 30 years ago.' Most perforations are a result of the catheter tip at the ano-rectal por- tion of the bowel. 1 Fatal complications have been described and some collec- tive series report a figure of 50% mor- tality. Others claim such figures are outdated and give lower figures such as 20% mortality. Some authors re- port even lower mortality due to more effective and efficient staff training.ê? Bowel perforation is reported to occur in 0.02-0.04% of patients un- dergoing barium investigations of the large bowel. I In the USA adult litera- 16 SAJOURNAL OF RADIOLOGY. August 2000 Williams et al outline the recognised complications of intraperitoneal bowel perforation during barium enema investigations. These include intravascular volume depletion, sepsis, adhesions and peritoneal fibrosis. Other reported complications are intramu- ral intravasation, barium impaction, allergic reac- tion and cardiac arrhyth- mia.' We have found no reports in the current lit- erature of barium entering the lymphatic system after intraperitoneal spill and this is reported as a unique feature. References 1. Williams et al. Recognition and prevention of barium enema complications. Curr Probl DiagnRadio1l991; 20(4): 123-151. 2. Cordon et al. Rectal perforation during barium enema. Report of a case. Dis Colon Rectum 1988; 31(7): 563-569. 3. Rimarenleo et al. Fatal complications related to diagnostic barium enema. Am J Forensic Med Patha11988; 9(1): 78-84. 4. Grobmeyer et al. Barium peritonitis. Am Surg 1984; 50(2): 116-120. 5. Hardy et al. Survival after colonic perforation during barium enema examination. Modified radical surgical debridement. Dis Colon Rectum 1983; 26(2): 116-118. 6. Eklof et al. Barium peritonitis. Experience of five paediatric cases. Paediatr Radial 1983; 13(1): 5-9.