Correspondence

Prevention of Barium Impaction

N Engl J Med 1998; 338:623-624February 26, 1998

Article

To the Editor:

We would like to comment on the Images in Clinical Medicine showing barium impaction in the sigmoid colon (Oct. 30 issue),1 because this complication is rare if some precautions are taken.

For two days before the examination the patient should be given a low-residue diet and fluids to ensure adequate hydration. On the day of the examination the patient should drink plenty of clear fluids. Laxatives with various actions may be given, such as stimulants (bisacodyl), hyperosmolar agents (magnesium sulfate), and directly acting substances (anthraquinone derivatives). We use ricinus oil and a solution containing 400 mg of senna with 5 mg of dexpanthenol per 5 ml. Cleansing enemas are reserved for bedridden or constipated patients.

We perform small-bowel investigation by positioning a large-bore tube at the level of the ligament of Treitz. Barium suspension (300 ml) is instilled at a rate of 75 ml per minute, followed by methylcellulose solution (600 ml). The follow-through is continued until the first barium evacuation is seen, after which the patient is encouraged to empty his or her bowels into the toilet.

Before the colonic investigation, the radiologist will fluoroscopically check for fecal residue. A rectal examination is routinely performed to look for a rectal mass and to ensure that the rectum is empty. A direct double-contrast investigation is also routinely performed with 300 ml of barium suspension. The barium is instilled in a retrograde fashion, and the patient is positioned to allow gravity to spread the barium to the cecum and terminal ileum. Air is insufflated to distend the colon. Approximately 75 percent of the instilled barium is evacuated from the rectum with the patient prone and semi-erect. A second method is reserved for patients who are in poor physical condition and those over 70 years of age, in whom the direct double-contrast technique is deemed too strenuous. In these patients, the barium solution is diluted to 1 liter and a single-contrast investigation is performed.

After the completion of either method of investigation, the cannula is left in place for 10 minutes to allow further drainage of the barium. After the cannula is removed, the patient is encouraged to evacuate his or her bowels into the toilet.

Using this approach, we have not encountered any patients with impacted barium fecaliths after small-bowel enteroclysis or colonic investigations in the past 10 years.

Edwin J.R. van Beek, M.D.
Jacques W.A.J. Reeders, M.D.
Academic Medical Center, 1105 AZ Amsterdam, the Netherlands

1 References

1. 1

   McDonnell WM, Jung F. Barium impaction in the sigmoid colon. N Engl J Med 1997;337:1278-1278
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Although we used techniques that were similar to those described by Drs. van Beek and Reeders, barium impaction still developed in our patient. We believe that it was not the technique of the barium study that led to complications in this debilitated, postsurgical patient but what occurred after the procedure. Attention to hydration, cleansing the bowel if necessary, and seeking medical care promptly if patients fail to have bowel movements are important in preventing impaction.

We surveyed five gastrointestinal-radiology departments to determine their post-procedure instructions. Four had no written instructions for the patient but verbally instructed patients to take plenty of fluids; two also told patients that they could take a laxative such as milk of magnesia. Only one department gave written instructions stating that the patients should “take a mild laxative . . . and drink more fluids than normal to help rid the body of barium” and that “laxatives may be repeated a second day, if needed.” Patients were instructed to “call the physician's office if [they did] not have a bowel movement within 48 hours.”

Drs. van Beek and Reeders imply that there have been no complications from barium studies performed in their department, but unless the data were obtained prospectively with follow-up telephone calls, they may have missed some patients who did have complications. When patients present with barium impaction, the problem is usually dealt with by physicians other than radiologists.

We believe attention should be directed especially to the patient's underlying medical condition and to the care given after a barium study.

W. Michael McDonnell, M.D.
Western Washington Medical Group, Everett, WA 98201

Frank Jung, M.D.
Johann Wolfgang Goethe Universität, 60590 Frankfurt, Germany