Barium in Surgery

Barium in SurgeryThat there is NO place for barium in the emergency surgical patient. The message is rather long; either ignore it or take a sip from a single malt, relax and enjoy.

Here it goes:

Emergency contrast studies in the surgical patient: The case against barium.

Surgeons order emergency gastrointestinal contrast studies mainly to diagnose, delineate or rule out intestinal obstruction or perforation . We contend that the use of barium in such circumstances is inappropriate in that the potential dangers outweigh the doubtful diagnostic advantages in the surgical patient.

Barium versus water-soluble contrast agents

The costly water-soluble contrast agents, exemplified by Gastrograffin, outline only the gross anatomy of the bowel, such as its patency and integrity. As they advance through the intestinal tract the hyperosmolar water-soluble agents become diluted and partially absorbed, losing their contrast properties. On the other hand barium sulphate, which is significantly cheaper, superbly delineates the small and large bowel, including mucosal details. Since it is not water-soluble it maintains its contrast qualities along the whole length of the bowel segment studied. These are the arguments offered by radiologists who recommend barium in preference to water-soluble agents.

Dangers of barium

Installation of barium sulphate into the peritoneal cavity may produce devastating local and systemic effects. Barium alone, injected into the peritoneal cavity of animals, has been shown to lead to local inflammatory reaction and death. Admixture of barium and feces has a far more lethal action than barium or feces alone, since barium tends to promote infection. As an adjuvant of intra-abdominal infection barium has been added to bacteria and/or feces to create models of experimental peritonitis. The severe peritonitis resulting from inadvertent leakage or spill of barium into the peritoneal cavity has been noted in numerous case reports since the turn of the century. In fact, nearly every surgeon recalls a case or two: the bowel contents plus barium admixture often sticks to the serosal surfaces and is difficult to eradicate. Radiographs taken even years after the events demonstrate free intra-cavitary barium suggesting that barium, once in the peritoneum, will stay there forever. Consequently, every surgeon and radiologist knows that barium is contra-indicated when the integrity of the gastrointestinal tract (or anastomosis) is in doubt. But perforations are not always clinically apparent and patients are commonly investigated before they are seen by a surgeon. As a consequence barium may be used in patients with unsuspected perforation of the intestine with catastrophic results. In our clinical experience a patient who underwent barium enema to investigate ” a partial colonic obstruction without any signs of perforation” experienced such a result. The barium flooded the left pleural cavity through a perforation resulting from a strangulated diaphragmatic hernia. This resulted in fulminant empyema which required prolonged drainage and decortication. The barium is still visible in the chest today.

The pre-operative use of barium can complicate subsequent emergency operations. A bowel clamp may slip off during resection of a barium-filled segment of obstructed small bowel or a linear stapler may misfire during creation of a barium-filled distal rectal segment in a Hartmann procedure and one is left to clean up the mess! Pre-operative barium enema may frustrate the performance of the increasingly popular one -stage procedure for the obstructed left colon, making intra-operative colonic cleansing almost impossible. Rarely, in the presence of chronic high grade partial intestinal obstruction, the thick barium may inspissate causing a full obstruction which necessitates emergency surgery.

Barium is notoriously difficult to eliminate following its use in upper or lower gastrointestinal studies. Once it has been utilized for a suspected surgical emergency it may interfere with subsequent radiography, making investigations such as CT scanning or angiography impossible. A week or more is often required for enemas and bowel “washout” to evacuate the bowel. Often, after emergency surgery in the aftermath of barium studies, patients form barium “rocks” in the rectum causing constipation and delay in the normalization of bowel function.

The advantages of water-soluble contrast agents

Water- soluble contrast agents are inferior in their ability to delineate gastrointestinal anatomic detail but are advantageous in other respects. When instilled into serosal cavities water-soluble agents are harmless in terms of tissue reaction or aggravation of infection. The hyperosmolar Gastrografin, when administered into the intestine, directly and osmotically increases the luminal fluid content, and has been shown to cause intestinal hyperperistalsis and transient distention. These properties have promoted its therapeutic use in the attempt to resolve postoperative adynamic ileus, intestinal obstruction caused by parasites, and partial mechanical small bowel obstruction. Given as an enema Gastrografin has been reported to relieve meconium ileus in neonates and decompress the dilated colon in colonic pseudo-obstruction. Many of our colleagues in Radiology have drawn attention to the potential hazards of water-soluble contrast media used in emergency situations, such as hypovolemia, electrolyte imbalance, aspiration of contrast leading to pulmonary edema, and perforation of the suddenly distended and hyperperistaltic loops of bowel. With judicious use, however, none of such feared derangements have been documented.

Do we need emergency barium studies at all?

It is common wisdom that whenever a breach in the integrity of the gastrointestinal tract is suspected barium is contra-indicated. What about the other indications for its use?

Small bowel:
About half of all episodes of small bowel obstruction are incomplete (partial, as defined on plain abdominal radiography by Brolin) and usually resolve spontaneously. Conversely, the chance that a complete obstruction will resolve spontaneously is remote, mandating an operation after a certain, (but controversial), period of observation. As such there is little rationale or indication for a contrast study in completely obstructed patients who are destined for surgery. In patients with non-resolving partial obstruction a contrast study may provide further information regarding the probability of eventual spontaneous resolution. This goal is best accomplished with Gastrografin which also may be therapeutic. Should the surgeon desire additional information concerning the anatomical detail of the intestinal tract or the cause of obstruction, CT scan with water-soluble contrast has been proven to be accurate.

Large bowel:
The rationale for contrast enema in suspected colonic obstruction is to distinguish between true mechanical obstruction and colonic pseudo-obstruction, the former requiring an operation and the latter usually not. What one wishes to know is whether there is an obstruction or not? Usually the left colon is obstructed and thus all that is needed is a contrast study to the level of the splenic flexure. The presence or absence of obstruction is well demonstrated using water-soluble contrast. The better visualization of mucosal details by barium is not clinically relevant in this situation in which one is searching for obstruction or perforation and not for polyps. For the diagnosis and staging of acute diverticular disease CT scanning with water soluble contrast has been shown to be more reliable than barium enema.

As we have shown barium in the emergency situation is, at best, potentially problematic and, at worst, dangerous. Why it is still widely used and abused? In most instances the decision to choose the contrast medium is left to the radiologist who prefers barium. The radiologist, however, often “treats the picture” but not necessarily the patient. The radiologist is not the one to be confronted in the middle of the night with a peritoneum filled with barium. Nonetheless the radiologist is the one who will delay further testing until the intestinal tract is free of barium. Surgeons should be aware that barium may be dangerous and insist that water soluble contrast media is used in emergency situations. Disasters with barium are rare but the associated morbidity is irritating and costly. There is no need for it, so let us stop using it.

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