Barium enemas

Barium enema, sigmoidoscopy, or colonoscopy maybe indicated in the presence of red flag symptoms (fever, weight loss, bleeding, and anemia, which maybe accompanied by persistent severe pain), which often point to a potentially serious non-IBS problem. A barium enema may identify polyps, diverticulosis,... 

One of the following after age 50 Sigmoidoscopy every 5 years Colonoscopy every 10 years Barium enema every 5-10 years... 

ALFT Abnormal liver function test BE Barium enema... 

Barium enema A diagnostic test using x-ray examination to view the lower gastrointestinal tract (colon and rectum) after oral ingestion of barium sulfate, a chalky liquid contrast medium. 

A series of examinations, including proctoscopy, sigmoidoscopy, colonoscopy, or barium enema, may be necessary to determine the presence of colorectal pathology. 

The entire large bowel should be evaluated by colonoscopy or flexible sigmoidoscopy with double-contrast barium enema. 

Nightingale SS Severe adverse reactions to barium enema procedures. JAMA 264 2863, 1991... 

The diagnosis is essentially by exclusion of discrete organic disease usually by barium enema and sigmoidoscopy, or colonoscopy. 

It is indicated in all forms of constipation, e.g. in bedridden patients, due to change of food or environment, illness or digestive disorders relief of evacuation in painful conditions such as haemorrhoids pre and postoperatively pre-paration for barium enema preparation of colon for proctosigmoidoscopy. Dose DULCOLAX 5-15 mg HS oral and suppository (5-10 mg). 

In comparison with the average effective dose equivalent to the general population from cosmic radiation, which approximates 0.27 mSv (27 mrem) annually, the average dose to the thorax of an individual from a standard x-ray examination of the chest is of the order of 0.10 mSv (10 mrem). Other diagnostic procedures may deliver substantially larger doses, e.g., the average effective dose equivalent of an individual from a barium enema examination of the colon is approximately 4 mSv (400 mrem). 

Numerous factors may be involved with the toxic substance itself. If the substance is a toxic heavy metal cation, the nature of the anion with which it is associated can be crucial. For example, barium ion, Ba2+, in the form of insoluble barium sulfate, BaS04, is routinely used as an x-ray opaque agent in the gastrointestinal tract for diagnostic purposes (barium enema x-ray). This is a safe procedure however, soluble barium salts such as BaCl2 are deadly poisons when introduced into the gastrointestinal tract. 

One death in an adult female due to acute intravasation of barium sulfate during a barium enema was found in the literature. Direct entry of barium sulfate into the circulatory system apparently resulted in cardiorespiratory failure (Cove and Snyder 1974). Acute parenteral administration of barium compounds to animals has resulted in death. Rate of administration, total dose, species, and individual differences are all factors affecting the ability of barium and its compounds to cause death. Major symptoms leading to death are hypokalemia (Jalinski et al. 1967 Roza and Berman 1971 Schott and McArdle 1974), muscle paralysis (Roza and Berman 1971 Schott and McArdle 1974), cardiorespiratory failure (Cove and Snyder 1974 Roza and Berman 1971), and convulsions (Segreti... 

Acute intravasation of barium sulfate into the circulatory system of an adult female patient following a barium enema procedure caused the compound to be deposited in blood vessels throughout the body, including the lungs, and resulted in respiratoryfailure (Cove and Snyder 1974). Acute parenteral administration of barium compounds to animals has been shown to result in paralysis of the respiratory muscles (Roza and Berman 1971). Similar respiratory paralysis is frequently encountered in cases of acute exposure in humans and animals by ingestion or inhalation. Intratracheal administration of barium sulfate into rat lungs produced a mild inflammatory reaction (Huston et al. 1952). Barium sulfate could not be removed by either polymorphonuclear leukocytes or monocytes. A tissue reaction followed however, no fibrosis was observed. Since this mode of entry is similar to inhalation, these results may be significant for cases of inhalation exposure. 

Two case studies of acute intrusion of barium sulfate into the peritoneal space during barium enema examination of four men showed barium sulfate caused an acute inflammatory tissue response (Kay 1954 Yamamura et al. 1985), and in one case resulted in formation of a fibrous granuloma (Kay 1954). This is an extremely rare mode of entry and not of significant concern for individuals exposed at a hazardous waste site. Increased fluid accumulation in the intestinal lumen of rats was observed after intraperitoneal injection of barium chloride (Hardcastle et al. 1983b, 1985) however, this observation is not significant for individuals exposed at hazardous waste sites because of the route of exposure and because there has been no documentation of this effect occurring in humans following normal exposure routes. 

Other Systemic Effects. Other systemic effects have been observed. Barium sulfate was observed to act as an appendocolith in two cases following barium enema procedures (Palder and Dalessandri 1988). This is a rare occurrence and probably not significant in cases of human barium toxicity. Intravenous injection of barium sulfate into pigs increased calcitonin secretion from the thyroid (Pento 1979). This is probably not a significant effect for humans since intravenous exposure is not a common route and the dose required was so high (1.7 mg/kg/minute for 20 minutes) it caused cardiotoxicity. 

Berman CZ, Jacobs MG, Bernstein A. 1965. Hazards of the barium enema examination as studied by electrocardiographic telemetry Preliminary report. J Amer Geri Soc 13 672-686. 

Cove JKJ, Snyder RN. 1974. Fatal barium intravasation during barium enema. Radiology 112 9-10. 

Eastwood GL. 1972. ECG abnormalities associated with the barium enema. J Am Med Assoc 219 719-721. 

Feczko PJ, Simms SM, Bakirci N. 1989. Fatal hypersensitivity reaction during a barium enema. Am J Roentgenol 153 275-276. 

Gibbs G, Lueker RD, Baxley WA, et al. 1972. Cardiac arrhythmia associated with barium enema. Rocky Mt Med J 69 63-66. 

Roeske WR, Higgins C, Karliner JS, et al. 1975. Incidence of arrhythmias and ST-segment changes in elderly patients during barium enema studies. Amer Heart J 90 688-694. 

Stremple J, Montgomery C. 1961. Nonspecific electrocardiographic abnormalities The EKG during the barium enema procedure. Marquette Med Rev 27 20-24. 

Oral barium sulfate is theoretically non-toxic, but constipation and abdominal pain are not uncommon after barium meals or barium enemas (1). The main risk is that collections of barium wiU remain in the colon they can persist for 6 weeks or longer in elderly patients or cases of colonic obstruction barium fecoliths may even have to be removed surgically. Prolonged stasis of barium can occur after a barium enema into the distal loop of a colostomy. Residues in the appendix have caused appendicitis. Toxic dilatation of the colon can be aggravated by barium sulfate. 

Electrocardiographic changes have been recorded during administration of barium enemas and could represent a hazard in cases of cardiac disease (2-4). 

After a barium enema, perforation occurs rarely in children and debilitated adults or when the colon is already weakened by inflammatory, malignant, or parasitic diseases. Perforation can be triggered by manipulations involved in giving the barium enema or can result from hydrostatic pressure. In one case, perforation followed air contrast insufflation for barium enema in a patient in whom the sigmoid colon became trapped in an inguinal hernia. 

At least 12 cases of perforation of the colon by barium enema, with four deaths, were reported in a series of publications (SED-12,1165) (6-8). The incidence of perforation was about 1 in 6000 examinations. Even sterile barium sulfate can cause marked peritoneal irritation, with considerable fluid loss into the peritoneal cavity, but in practice it is usually a mixture of barium and feces that escapes and this, not surprisingly, produces severe peritonitis and dense adhesions. Mortality has been reported to be 58% with conservative treatment, and as high as 47% with surgical intervention (9). Early operation is indicated, and large volumes of intravenous fluids improve the prognosis. Patients who recover can... 

In air-contrast examinations, colonic perforation can actually precede the administration of the barium enema itself. In such cases it is due to the preparatory insufflation of air if this is conducted with excessive enthusiasm in a high-risk patient (for example an elderly patient with a hitherto unrecognized epigastric hernia) (10). 

Extraperitoneal perforation and leakage of barium may cause few immediate symptoms, but delayed endo-toxic shock can develop some 12 hours later, often causing death. Bowel infarction can also result. Barium granulomata can occur, causing painful masses, rectal strictures, or ulcers. On proctoscopy, an ulcer with a whitish base can mimic a carcinoma. In one rare case, perforation of a barium enema into a sigmoid abscess was followed by intravasation into the portal venous system (11). 

Reactions to other constituents of barium sulfate enemas have been recognized (SEDA-18, 441) and could be as common as one in 1000. They vary from urticarial rashes to severe anaphylactic reactions, and can be particularly severe in patients with asthma (13). Hypersensitivity to the latex balloon catheter used in double contrast barium enemas appears to be a common mechanism (14), but hypersensitivity to glucagon, to the preservative methylparabens, or to other additives seems to be responsible in some cases. Insofar as the latex balloon is concerned, thorough washing will remove the allergen responsible for the reaction (15). 

Transient bacteremia was recorded in 11.4% of a series of 175 patients who had undergone barium enema examination it appeared almost at once and lasted up to 15 minutes (16). Although a second study elsewhere failed to confirm these findings, a subsequent fatal case of staphylococcal septicemia in an elderly patient with an immune deficiency suggests that the risks are not merely theoretical (17). 

Tannic acid (up to 1.5%) was at one time added to barium enemas in order to improve the quality of the radiological picture. Tannic acid is hepa to toxic and fulminant Uver disease very occasionally resulted. Although it was perhaps avoidable, being apparently associated mainly with higher tannic acid concentrations, mucosal damage, or a prior tannic acid washout of the bowel, the risks have made this technique obsolete. 

Accidental administration of a barium enema into the vagina instead of the rectum can occur and can be very hazardous in some of these patients there has been fatal rupture of the vagina, with venous intravasation of the barium. 

Accidental venous intravasation of barium during administration of a barium enema usually has a high immediate mortality, due to barium embolism in the lungs, but it occasionally causes few symptoms. In one intermediate case there was hypotension and evidence of disseminated intravascular coagulation (SEDA-9, 407) the patient recovered after intensive treatment. 

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