What is the treatment approach for barium infiltration?

Treatment Approach for Barium Infiltration

Immediate surgical intervention with removal of extravasated barium and drainage is the recommended treatment for barium infiltration, especially in cases of intraperitoneal perforation. 1, 2

Initial Management

• Prompt recognition of barium infiltration is crucial as it can be life-threatening, with perforation being the most common serious complication of barium enema procedures (occurring in approximately 0.02% to 0.04% of patients) 3
• Initial stabilization should include:
  • Fluid resuscitation to address intravascular volume depletion and prevent shock 3
  • Broad-spectrum antibiotic therapy to prevent or treat infection and sepsis 1
  • NPO (nothing by mouth) status until surgical intervention 2

Surgical Management

• For intraperitoneal barium infiltration:

  • Emergency laparotomy is required to remove extravasated barium and fecal material 1
  • Creation of a proximal diverting colostomy is typically necessary 1, 2
  • Thorough irrigation of the peritoneal cavity to remove as much barium as possible 2
  • In some cases, bowel resection may be required if there is significant damage 1

• For retroperitoneal barium infiltration:

  • Large retroperitoneal perforations should be managed similarly to intraperitoneal perforations with surgical exploration and drainage 1
  • Smaller retroperitoneal perforations may be managed conservatively with close monitoring, but surgical intervention is indicated if the patient's condition deteriorates 1, 4

Post-Surgical Care

• Continued antibiotic therapy is recommended to prevent infection 1
• Close monitoring for complications including:
  • Sepsis and multiple organ failure, which are major causes of mortality 2
  • Formation of dense intraperitoneal adhesions 3
  • Development of abscesses, cellulitis, or fistulae 3
  • Submucosal barium granulomas that may ulcerate or be mistaken for neoplasms 3

Prognosis and Complications

• Mortality can be high, with two out of four patients in one case series dying from multiple organ failure despite surgical intervention 2
• Recovery time varies significantly, with hospital stays ranging from 20 days to four months postoperatively 1
• Long-term complications may include:
  • Intestinal strictures
  • Chronic pain
  • Adhesive bowel obstruction
  • Rectal strictures or fistulae 3

Prevention Strategies

• Careful patient selection and review of clinical history to identify high-risk patients 3
• Use of air instead of barium for certain procedures (such as intussusception reduction) may be safer as air is relatively inert if perforation occurs 5
• Proper technique during barium enema procedures, including careful insertion of the enema tip and appropriate inflation of retention balloons 3

Special Considerations

• Patients at higher risk for perforation include:
  • Elderly patients
  • Those on long-term steroid therapy
  • Patients with underlying bowel disease (neoplasm, diverticulitis, inflammatory bowel disease, ischemia) 3
  • Recent deep biopsy or polypectomy sites 3

The management of barium infiltration requires prompt surgical intervention and aggressive supportive care to improve outcomes in what can be a potentially fatal complication.