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Intramesenteric perforation of sigmoid diverticulitis with nonfatal venous intravasation
lntramesenteric Perforation of Sigmoid Diverticulitis with Nonfatal Venous lntravasation George L. Juler, MD, Long Beach, California William R. Dietrick, MD, Irvine, California Jack I. Eisenman, MD, Irvine, California
perforation is not only a rare complication of colonic diverticulitis but is one of the most occult manifestations of the disease. It may present as fever of unknown etiology, jaundice, generalized lower abdominal pain, or generalized sepsis. Colon diverticulitis is complicated by perforation in approximately 8 per cent of patients of which 1 to 2 per cent are intramesenteric perforations [I]. The use of diagnostic barium enema is generally considered to be a safe clinical procedure, but when it is used to evaluate certain inflammatory diseases of the colon, grave complications can occur including iatrogenic perforation, water intoxication, and veIntramesenteric
nous intravasation, the latter being the gravest but fortunately rarest. In our review of the English literature we found only nine cases of venous intravasation from barium
enema. (Table I.) A tenth case from the German literature cited by Cove and Snyder [IO] is not included in this study since no mention is made of barium in blood vessels, liver, heart, or lungs. Colon disease was the indication for barium enema in all cases except in the two cases where it was used to evaluate rightsided abdominal masses. All patients but one were females, seven of whom were more than sixty-four years of age. The male patient was thirty-nine years old and was a survivor. The only young female was twenty-five years old, also a survivor. There were six sudden deaths (67 per cent) and three survivors (33 per cent). Those who survived the accident had only small amounts of barium intravasation. A fourth case of nonfatal venous intravasation of barium is the basis of this report.
From the Departments of Surgery and Radiology, Veterans Administration Hospital, Long Beach, and the Departments of Surgery and Radiology, University of California. College of Medicine, Irvine, California. Reprint requests should be addressed to George L. Juler, MD. Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, California 90801. Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, California, January 16, 1975.
Volume 132, November 1976
Case Report A thirty-five year old Caucasian male was admitted to Veterans Administration Hospital, Long Beach, California, on September 17,1969, with an eight day history of severe crampy lower abdominal pain, diarrhea, tenesmus, urinary frequency, fever, and chills. He had been treated in a private hospital for his first episode of colon diverticulitis five days prior to admission to our hospital. On physical examination he was acutely ill, dehydrated, septic, and jaundiced (serum bilirubin level, 4.3 mg/lOO ml). His temperature was 101.4“F, pulse 120/min, respiration 20/min, and blood pressure 80/54 mm Hg. His abdomen was exquisitely tender and tympanitic with involuntary guarding and rebound tenderness in the right upper quadrant. Barium enema x-ray films from the private hospital showed contrast material in the inferior mesenteric vein near the sigmoid colon and in a branch of the portal vein. (Figure 1.) Blood culture specimens were obtained and intravenous fluid resuscitation started. Broad spectrum antibiotics were added to the infusion. Twenty hours later on September 18, he was taken to the operating room where he was found to have an inflamed swollen sigmoid colon segment 10 to 12 cm proximal to the peritoneal reflexion. The mesocolon was swollen and edematous with a purulent exudate on the serosal surface. A thrombosed vein was seen on the mesenteric border of the colon. No abscess was found, but cloudy fluid obtained from the pelvis was sent to the laboratory for culture and chemical analysis. The rest of the abdomen including the liver showed nothing abnormal. Because of the patient’s extreme toxicity, only a diverting right upper quadrant loop colostomy was performed. This was completely divided one week later when sepsis failed to subside. Figure 2 is a close-up film of the liver showing barium in a branch of the right portal vein. Three weeks later on October 9, he was taken back to the operating room for sigmoid colon resection because of continued sepsis. He was found to have an abscess in the pelvis containing 40 ml of pus which contained gram-negative rods on smear. He was started on cephalosporin and kanomycin antibiotics intraoperatively. Bacteriologic studies later proved the organism to be Escherichia coli sensitive only to gentamycin. The liver showed no signs of abscess and there was no evidence of portal vein thrombosis.
653
Juler, Dietrick, and Eisenman
TABLE
10 Reported
I
Nissen,
and
[Z] 1950 Roman, Wagner,
Epstein
and
25,
F
78, F
during
Barium
Indication Chronic
ulcerative
cohtis
73.
F
Right
1959 Truemner.
abdominal
mass
White,
76,
F
Obstructive diverticulitis
sigmoid
[51
lower
quadrant
1960 Z&kin
and
Irwin
[61
65.
F
1964
[ 71
Frecker Noveroske
1968 [8]
Catheter Tip Location
Site of lntravaration
?
Rectum
Transverse
+
Rectum
Rectum
Result colon
81.
Right upper quadrant abdominal
Rapid
F
mass Diverticulosis
of sig-
Rectum
Rectum
Rapid
+
Rectum
Rectum
Rapid death
death
Vagina
Survival
Vagina
Cove 1974 present
et al [9] and
Snyder
Barium veins nary Barium
Barium
and
renal
pulmonary
in pelvic
artery
veins,
pulmo-
artery, and heart in hemorrhoidal
kidneys,
and
veins,
lungs
in pelvic
and
left
renal
lungs
+
Rectum
Rectum
Rapid
Barium
*
Rectum
Rectosigmoid
death Rapid death
and right renal Barium in pelvic
Survival
Barium
in inferior in bladder,
in pelvic,
inferior veins veins,
iliac,
72,
F
39,
M
Slgmoid
diverticulitis
+
Rectum
Sigmoid
[IO]
64,
F
Sigmoid
diverticulitis
+
Rectum
Sigmoidcolon
Rapid
vein Barium
Sigmoid
death Survival
kidney, heart, lungs.and brain Barium in inferior inesenteric
35,
M
Sigmoid
diverticulitis
+
Rectum
colon
colon
vena
and intraluminal
cava.
portal
and
right
inferior heart
meSenteriC uterus,
veins
oressure.
The patient survived a very stormy postoperative course consistent with generalized septicemia. To evaluate his continued sepsis, selective celiac angiography was performed on October 22, two weeks after the colon resection. This study shows occlusion of the right portal vein. (Figure 3.) The splenic artery and spleen were enlarged. (Figure 4.1
Figure 1. Barium is seen in the inferiormesenterk vein near the sigmoid colon. II can also be seen in the portal vein and liver.
654
Findings
1973
report
*Increased
in pelvic and
Barium
veins,
COIO” Nordahl
or Autopsy
moid Sigmoid
1970
colon volvulus
+
+
X-Ray
Survival
death
[3] 1952 and Fine [4]
Vanlindlngham
Catheter
Obstipation
Steinbach Rosenberg
and
Enema Bardex
Age (yr) and Sex
Author Isaacs.
Cases of lntravasation ___.-
Repeated postoperative blood cultures grew only on “unidentified” gram-negative rod, but his sputum grew a heavy growth of E coli organisms. He had been treated with gentamycin for the first postoperative weekend then switched to penicillin and chloromycetin for three weeks because of hearing loss and failure of his sepsis to respond to treatment. The venous phase of a superior mesenteric arteriogram on November 26, showed collateral channels about the portal vein. (Figure 5.) On November 28, he was started on tetracyclene and ampicillin after which his sepsis gradually subsided and he became afebrile on December 6, just three months after onset of his illness. Other complications encountered during treatment were transfusion hepatitis and hearing loss secondary to use of aminoglycoside antibiotics. Repeated liver biopsies showed nonspecific focal necrosis, cholestasis, and mild fibrosis. He had received a total of 18 units of blood during treat-
Figure 2. A close-up film of the liver shows barium In the right branch of the portal vein.
The American Journal ol Surgery
Sigmoid Diverticulitis
ment. At time of discharge from the hospital on January 26,1970, his blood count, chemistries, and enzymes had all returned to within normal limits. He returned on October 8,197O and had his right upper quadrant transverse colostomy closed with an uneventful postoperative course. By this time he had regained his normal weight of 140 pounds. He remains well to this date. Comments Complications and risks associated with diagnostic barium enema have been reported [11-131. Perforation of the bowel, most often in the rectosigmoid colon, is the most common serious accident with a mortality rate of 15 to 50 per cent [7]. The gravest but rarest of complications is venous intravasation with a mortality of 67 per cent in reported cases. This accident is extremely rare as indicated by the nine scattered reports in the literature, our case is only the
tenth report. However, the true incidence may be higher than this report indicates. We are aware of other cases in our community that have not been reported. Many subclinical cases go unrecognized due to mild transient symptoms. Patients frequently become restless, apprehensive, cyanotic, tachypneic, or dyspneic during barium enema. These symptoms are not unlike those of pulmonary emboli associated with phlebitis and are attributed to anxiety or the physical discomfort of the procedure [5,6,10]. It is regrettable that more of these cases are not reported so that a better understanding of the pathogenesis could be developed. The pathogenesis of this accident remains obscure but several factors are implicated. The anatomic proximity of the hemorrhoidal plexus of veins to the rectal mucosa, the diminishing elasticity of the rec&l wall with age, and the distension of the thin rectal wall of the elderly are fundamental predisposing factors [7]. On the basis of the reported cases, preexisting colonic disease, minor trauma to the submucosal veins, the “asperating” ability of venous channels, and the presence of increased intraluminal pressure in the distal colon are factors that contribute to barium intravasation 151. In our study of the nine reported cases, the cause of intravasation was not determined in those three patients who underwent autopsy [3,5,10]. However, barium was radiographically seen entering pelvic or hemorrhoidal veins from the rectum in the three patients who did not have postmortem examinations [4,7,8]. Chronic ulcerative colitis of the transverse colon, a 3 inch vaginal laceration due to a misplaced catheter tip, and sigmoid diverticulitis were the sites of intravasation in three patients who survived the accident [2,6,9]. These three patients sustained only small
amounts
of barium
intravasation
as did our.
Figure 3. The venous phase of selective ceiiac angiggraphy five weeks past intravasation shows occlusion of the right portal vein.
Figure 4. The atfertal phase of sebctive cefiac angiography shows enlargement of the splenic artery and spleen.
Juler, Dietrick, and Eisenman
The cause of intravasafion in our patient was found in the resected sigmoid colon. There was free communication between a single diverticulum and the intramesenteric abscess. The abscess was surrounded by several large thrombosed veins. The use of the balloon catheter or elevated intraluminal pressure was associated with intravasatjon in all but one case. (Table I.) However, there is no evidence to suggest that excessive inflation of the catheter balloon occurred in any of these cases. It would seem that the high association of this accident with the use of the balloon catheter is more than just coincidental and that elderly women are more at risk during barium enema than younger patients since eight of the nine patients were women, of whom seven were more than sixty-four years old. Survival after this accident is infrequent as indicated by the six deaths in the previously reported cases (67 per cent). Most patients expire within minutes after intravasation of a significant amount. The rapidity of death is associated with the free communication of the hemorrhoidal plexus of veins with the portal or systemic circulation so that barium can readily embolize to the liver, heart, or lungs [5]. The amount of intravasation apparently determines survival [6]. Small amounts of barium can be seen in the pelvic veins or in the lungs during hysterosalpingography without serious complications or death [3,6]. All patients in this study who survived, including our patient, sustained only a small amount of barium intravasation, whereas all patients who died rapidly (6 patients) had large amounts of barium in the pelvic, hemorrhoidal, hypogastric, common iliac, inferior mesenteric, ovarian, renal, inferior vena cava, portal, and hepatic veins, the kidneys, liver, heart, and lungs. Diverticular disease of the colon, chronic ulcerative colitis, and sigmoid volvulus were associated with barium intravasation in’seven of the ten cases in this study. Only three patients had no demonstrable colon disease. Therefore, the presence of inflammatory colon disease or obstruction should make the radiologist doing the barium study highly aware of the possibility that barium embolization can occur either covertly or overtly. The use of selective celiac angiography in our patient to evaluate his continuing sepsis after removal of the sigmoid diverticulitis led to the diagnosis of complicating pylephlebitis with portal vein obown patient who survived.
656
struction. (Figure 4.) It also enabled us to detect the onset of early portal hypertension as indicated by the large spleen and splenic artery. (Figure 3.) This information is most valuable in prognosis and follow-up care of this patient. The risk of intravasation during barium enema is very small but highly lethal when it does occur. Extreme caution is recommended when it is necessary to do a barium enema on elderly patients, especially females, with inflammatory disease of the colon. Their survival may depend on early recognition of intravasation. Selective visceral angiography is useful in determining the type and extent of complications associated with this accident. Summary
Complications from barium enema are rare (0.035 per cent). A patient with venous intravasation during barium enema complicated by pylephlebitis and portal vein obstruction is the tenth to be reported on, the fourth to survive. This accident was associated with colon disease in eight of the patients studied, five of whom had diverticular disease. References 1.
Bell JW: lntrarnesenteric perforationof colon diierticuktis. Arch
Surg 102: 471, 1971. 2. lsaacs I, Nissen R, Epstein BS: Liver abscess resulting from barium enema in a case of chronic ulcerative colitis. NY State J Med 50: 332, 1950. 3. Roman PW, Wagner JH, Steinbach St-f: Massive fatal embolism during barium enema study. Radiology 59: 190, 1952. 4. Rosenberg LS. Fine A: Fatal venous intravasation of barium during a barium enema. Radiology 73: 771, 1959. 5. Truemner KM. White S. Vanlandinoham H: Fatal embolization of pulmonary capillaries. Report of a case associated with routine barium enema. JAMA 173: 1089. 1960. 6. Zatkin HR, Irwin GAI: Non-fatal intravasation of barium. Am J Roentgenol92: 1169, 1964. 7. Frecker BE: Venous intravasation of the barium enema. Australas Rad~ol 12: 129. 1968. 8. Noveroske RI: Barium sulfate into the heart from extraperitoneat ruptue of the rectosigmokt. J Indiana State h&d Assoc
63: 23. 1970. 9. Nordahl DL, Siber FJ, Robbins AH, O’Hara ET: Non-fatal venous intravasation from the site of diverticulitis during barium enema examination. Am J Dig Dis 18: 253. 1973. 10. Cove JKJ. Snyder RN: Fatal barium intravasation during barium enema. Radiology 112: 9. 1974. 11. Seaman WB. Wells J: Complications of the barium enema. Gastroenterology 48: 728, 1965. 12. DiCarlo J Jr: Complications associated with diagnostic barium enema. Surgery 47: 965, 1960. 13. Porter EC: The risk of barium enema. J Maine Med Assoc 5 1: 422, 1960.
Tha Amerkan Journal of Surgwy
perforation is not only a rare complication of colonic diverticulitis but is one of the most occult manifestations of the disease. It may present as fever of unknown etiology, jaundice, generalized lower abdominal pain, or generalized sepsis. Colon diverticulitis is complicated by perforation in approximately 8 per cent of patients of which 1 to 2 per cent are intramesenteric perforations [I]. The use of diagnostic barium enema is generally considered to be a safe clinical procedure, but when it is used to evaluate certain inflammatory diseases of the colon, grave complications can occur including iatrogenic perforation, water intoxication, and veIntramesenteric
nous intravasation, the latter being the gravest but fortunately rarest. In our review of the English literature we found only nine cases of venous intravasation from barium
enema. (Table I.) A tenth case from the German literature cited by Cove and Snyder [IO] is not included in this study since no mention is made of barium in blood vessels, liver, heart, or lungs. Colon disease was the indication for barium enema in all cases except in the two cases where it was used to evaluate rightsided abdominal masses. All patients but one were females, seven of whom were more than sixty-four years of age. The male patient was thirty-nine years old and was a survivor. The only young female was twenty-five years old, also a survivor. There were six sudden deaths (67 per cent) and three survivors (33 per cent). Those who survived the accident had only small amounts of barium intravasation. A fourth case of nonfatal venous intravasation of barium is the basis of this report.
From the Departments of Surgery and Radiology, Veterans Administration Hospital, Long Beach, and the Departments of Surgery and Radiology, University of California. College of Medicine, Irvine, California. Reprint requests should be addressed to George L. Juler, MD. Veterans Administration Hospital, 5901 East Seventh Street, Long Beach, California 90801. Presented at the Annual Meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, California, January 16, 1975.
Volume 132, November 1976
Case Report A thirty-five year old Caucasian male was admitted to Veterans Administration Hospital, Long Beach, California, on September 17,1969, with an eight day history of severe crampy lower abdominal pain, diarrhea, tenesmus, urinary frequency, fever, and chills. He had been treated in a private hospital for his first episode of colon diverticulitis five days prior to admission to our hospital. On physical examination he was acutely ill, dehydrated, septic, and jaundiced (serum bilirubin level, 4.3 mg/lOO ml). His temperature was 101.4“F, pulse 120/min, respiration 20/min, and blood pressure 80/54 mm Hg. His abdomen was exquisitely tender and tympanitic with involuntary guarding and rebound tenderness in the right upper quadrant. Barium enema x-ray films from the private hospital showed contrast material in the inferior mesenteric vein near the sigmoid colon and in a branch of the portal vein. (Figure 1.) Blood culture specimens were obtained and intravenous fluid resuscitation started. Broad spectrum antibiotics were added to the infusion. Twenty hours later on September 18, he was taken to the operating room where he was found to have an inflamed swollen sigmoid colon segment 10 to 12 cm proximal to the peritoneal reflexion. The mesocolon was swollen and edematous with a purulent exudate on the serosal surface. A thrombosed vein was seen on the mesenteric border of the colon. No abscess was found, but cloudy fluid obtained from the pelvis was sent to the laboratory for culture and chemical analysis. The rest of the abdomen including the liver showed nothing abnormal. Because of the patient’s extreme toxicity, only a diverting right upper quadrant loop colostomy was performed. This was completely divided one week later when sepsis failed to subside. Figure 2 is a close-up film of the liver showing barium in a branch of the right portal vein. Three weeks later on October 9, he was taken back to the operating room for sigmoid colon resection because of continued sepsis. He was found to have an abscess in the pelvis containing 40 ml of pus which contained gram-negative rods on smear. He was started on cephalosporin and kanomycin antibiotics intraoperatively. Bacteriologic studies later proved the organism to be Escherichia coli sensitive only to gentamycin. The liver showed no signs of abscess and there was no evidence of portal vein thrombosis.
653
Juler, Dietrick, and Eisenman
TABLE
10 Reported
I
Nissen,
and
[Z] 1950 Roman, Wagner,
Epstein
and
25,
F
78, F
during
Barium
Indication Chronic
ulcerative
cohtis
73.
F
Right
1959 Truemner.
abdominal
mass
White,
76,
F
Obstructive diverticulitis
sigmoid
[51
lower
quadrant
1960 Z&kin
and
Irwin
[61
65.
F
1964
[ 71
Frecker Noveroske
1968 [8]
Catheter Tip Location
Site of lntravaration
?
Rectum
Transverse
+
Rectum
Rectum
Result colon
81.
Right upper quadrant abdominal
Rapid
F
mass Diverticulosis
of sig-
Rectum
Rectum
Rapid
+
Rectum
Rectum
Rapid death
death
Vagina
Survival
Vagina
Cove 1974 present
et al [9] and
Snyder
Barium veins nary Barium
Barium
and
renal
pulmonary
in pelvic
artery
veins,
pulmo-
artery, and heart in hemorrhoidal
kidneys,
and
veins,
lungs
in pelvic
and
left
renal
lungs
+
Rectum
Rectum
Rapid
Barium
*
Rectum
Rectosigmoid
death Rapid death
and right renal Barium in pelvic
Survival
Barium
in inferior in bladder,
in pelvic,
inferior veins veins,
iliac,
72,
F
39,
M
Slgmoid
diverticulitis
+
Rectum
Sigmoid
[IO]
64,
F
Sigmoid
diverticulitis
+
Rectum
Sigmoidcolon
Rapid
vein Barium
Sigmoid
death Survival
kidney, heart, lungs.and brain Barium in inferior inesenteric
35,
M
Sigmoid
diverticulitis
+
Rectum
colon
colon
vena
and intraluminal
cava.
portal
and
right
inferior heart
meSenteriC uterus,
veins
oressure.
The patient survived a very stormy postoperative course consistent with generalized septicemia. To evaluate his continued sepsis, selective celiac angiography was performed on October 22, two weeks after the colon resection. This study shows occlusion of the right portal vein. (Figure 3.) The splenic artery and spleen were enlarged. (Figure 4.1
Figure 1. Barium is seen in the inferiormesenterk vein near the sigmoid colon. II can also be seen in the portal vein and liver.
654
Findings
1973
report
*Increased
in pelvic and
Barium
veins,
COIO” Nordahl
or Autopsy
moid Sigmoid
1970
colon volvulus
+
+
X-Ray
Survival
death
[3] 1952 and Fine [4]
Vanlindlngham
Catheter
Obstipation
Steinbach Rosenberg
and
Enema Bardex
Age (yr) and Sex
Author Isaacs.
Cases of lntravasation ___.-
Repeated postoperative blood cultures grew only on “unidentified” gram-negative rod, but his sputum grew a heavy growth of E coli organisms. He had been treated with gentamycin for the first postoperative weekend then switched to penicillin and chloromycetin for three weeks because of hearing loss and failure of his sepsis to respond to treatment. The venous phase of a superior mesenteric arteriogram on November 26, showed collateral channels about the portal vein. (Figure 5.) On November 28, he was started on tetracyclene and ampicillin after which his sepsis gradually subsided and he became afebrile on December 6, just three months after onset of his illness. Other complications encountered during treatment were transfusion hepatitis and hearing loss secondary to use of aminoglycoside antibiotics. Repeated liver biopsies showed nonspecific focal necrosis, cholestasis, and mild fibrosis. He had received a total of 18 units of blood during treat-
Figure 2. A close-up film of the liver shows barium In the right branch of the portal vein.
The American Journal ol Surgery
Sigmoid Diverticulitis
ment. At time of discharge from the hospital on January 26,1970, his blood count, chemistries, and enzymes had all returned to within normal limits. He returned on October 8,197O and had his right upper quadrant transverse colostomy closed with an uneventful postoperative course. By this time he had regained his normal weight of 140 pounds. He remains well to this date. Comments Complications and risks associated with diagnostic barium enema have been reported [11-131. Perforation of the bowel, most often in the rectosigmoid colon, is the most common serious accident with a mortality rate of 15 to 50 per cent [7]. The gravest but rarest of complications is venous intravasation with a mortality of 67 per cent in reported cases. This accident is extremely rare as indicated by the nine scattered reports in the literature, our case is only the
tenth report. However, the true incidence may be higher than this report indicates. We are aware of other cases in our community that have not been reported. Many subclinical cases go unrecognized due to mild transient symptoms. Patients frequently become restless, apprehensive, cyanotic, tachypneic, or dyspneic during barium enema. These symptoms are not unlike those of pulmonary emboli associated with phlebitis and are attributed to anxiety or the physical discomfort of the procedure [5,6,10]. It is regrettable that more of these cases are not reported so that a better understanding of the pathogenesis could be developed. The pathogenesis of this accident remains obscure but several factors are implicated. The anatomic proximity of the hemorrhoidal plexus of veins to the rectal mucosa, the diminishing elasticity of the rec&l wall with age, and the distension of the thin rectal wall of the elderly are fundamental predisposing factors [7]. On the basis of the reported cases, preexisting colonic disease, minor trauma to the submucosal veins, the “asperating” ability of venous channels, and the presence of increased intraluminal pressure in the distal colon are factors that contribute to barium intravasation 151. In our study of the nine reported cases, the cause of intravasation was not determined in those three patients who underwent autopsy [3,5,10]. However, barium was radiographically seen entering pelvic or hemorrhoidal veins from the rectum in the three patients who did not have postmortem examinations [4,7,8]. Chronic ulcerative colitis of the transverse colon, a 3 inch vaginal laceration due to a misplaced catheter tip, and sigmoid diverticulitis were the sites of intravasation in three patients who survived the accident [2,6,9]. These three patients sustained only small
amounts
of barium
intravasation
as did our.
Figure 3. The venous phase of selective ceiiac angiggraphy five weeks past intravasation shows occlusion of the right portal vein.
Figure 4. The atfertal phase of sebctive cefiac angiography shows enlargement of the splenic artery and spleen.
Juler, Dietrick, and Eisenman
The cause of intravasafion in our patient was found in the resected sigmoid colon. There was free communication between a single diverticulum and the intramesenteric abscess. The abscess was surrounded by several large thrombosed veins. The use of the balloon catheter or elevated intraluminal pressure was associated with intravasatjon in all but one case. (Table I.) However, there is no evidence to suggest that excessive inflation of the catheter balloon occurred in any of these cases. It would seem that the high association of this accident with the use of the balloon catheter is more than just coincidental and that elderly women are more at risk during barium enema than younger patients since eight of the nine patients were women, of whom seven were more than sixty-four years old. Survival after this accident is infrequent as indicated by the six deaths in the previously reported cases (67 per cent). Most patients expire within minutes after intravasation of a significant amount. The rapidity of death is associated with the free communication of the hemorrhoidal plexus of veins with the portal or systemic circulation so that barium can readily embolize to the liver, heart, or lungs [5]. The amount of intravasation apparently determines survival [6]. Small amounts of barium can be seen in the pelvic veins or in the lungs during hysterosalpingography without serious complications or death [3,6]. All patients in this study who survived, including our patient, sustained only a small amount of barium intravasation, whereas all patients who died rapidly (6 patients) had large amounts of barium in the pelvic, hemorrhoidal, hypogastric, common iliac, inferior mesenteric, ovarian, renal, inferior vena cava, portal, and hepatic veins, the kidneys, liver, heart, and lungs. Diverticular disease of the colon, chronic ulcerative colitis, and sigmoid volvulus were associated with barium intravasation in’seven of the ten cases in this study. Only three patients had no demonstrable colon disease. Therefore, the presence of inflammatory colon disease or obstruction should make the radiologist doing the barium study highly aware of the possibility that barium embolization can occur either covertly or overtly. The use of selective celiac angiography in our patient to evaluate his continuing sepsis after removal of the sigmoid diverticulitis led to the diagnosis of complicating pylephlebitis with portal vein obown patient who survived.
656
struction. (Figure 4.) It also enabled us to detect the onset of early portal hypertension as indicated by the large spleen and splenic artery. (Figure 3.) This information is most valuable in prognosis and follow-up care of this patient. The risk of intravasation during barium enema is very small but highly lethal when it does occur. Extreme caution is recommended when it is necessary to do a barium enema on elderly patients, especially females, with inflammatory disease of the colon. Their survival may depend on early recognition of intravasation. Selective visceral angiography is useful in determining the type and extent of complications associated with this accident. Summary
Complications from barium enema are rare (0.035 per cent). A patient with venous intravasation during barium enema complicated by pylephlebitis and portal vein obstruction is the tenth to be reported on, the fourth to survive. This accident was associated with colon disease in eight of the patients studied, five of whom had diverticular disease. References 1.
Bell JW: lntrarnesenteric perforationof colon diierticuktis. Arch
Surg 102: 471, 1971. 2. lsaacs I, Nissen R, Epstein BS: Liver abscess resulting from barium enema in a case of chronic ulcerative colitis. NY State J Med 50: 332, 1950. 3. Roman PW, Wagner JH, Steinbach St-f: Massive fatal embolism during barium enema study. Radiology 59: 190, 1952. 4. Rosenberg LS. Fine A: Fatal venous intravasation of barium during a barium enema. Radiology 73: 771, 1959. 5. Truemner KM. White S. Vanlandinoham H: Fatal embolization of pulmonary capillaries. Report of a case associated with routine barium enema. JAMA 173: 1089. 1960. 6. Zatkin HR, Irwin GAI: Non-fatal intravasation of barium. Am J Roentgenol92: 1169, 1964. 7. Frecker BE: Venous intravasation of the barium enema. Australas Rad~ol 12: 129. 1968. 8. Noveroske RI: Barium sulfate into the heart from extraperitoneat ruptue of the rectosigmokt. J Indiana State h&d Assoc
63: 23. 1970. 9. Nordahl DL, Siber FJ, Robbins AH, O’Hara ET: Non-fatal venous intravasation from the site of diverticulitis during barium enema examination. Am J Dig Dis 18: 253. 1973. 10. Cove JKJ. Snyder RN: Fatal barium intravasation during barium enema. Radiology 112: 9. 1974. 11. Seaman WB. Wells J: Complications of the barium enema. Gastroenterology 48: 728, 1965. 12. DiCarlo J Jr: Complications associated with diagnostic barium enema. Surgery 47: 965, 1960. 13. Porter EC: The risk of barium enema. J Maine Med Assoc 5 1: 422, 1960.
Tha Amerkan Journal of Surgwy