Massive Fatal Embolism During Barium Enema Study

Abstract

Barium sulfate suspension has passed through the wall of the intestinal tract during a barium enema study when a perforation has been present. Opaque material from the uterus has on occasion entered into the pelvic veins during hysterosalpingography. The passage of barium through the mucosa of the colon into the venous system is, however, a medical curiosity. A careful search of the literature has revealed only one report of barium entering the veins. This occurred during the course of a barium enema in a patient with ulcerative colitis, resulting in liver abscess (1). In the case to be reported here no grossly demonstrable lesion of the colon existed. Barium passed through the wall of the rectum into the pelvic veins and thence to the lungs, with immediate fatality. Case Report A 78-year-old white woman was admitted to the Lutheran Hospital of Maryland on Aug. 30, 1950, in a stuporous condition. During the four years prior to admission, she had been known to have hypertension, and in the last two years, she had had five convulsive seizures. Two weeks prior to the present admission, she began to refuse all foods; she grew progressively weaker, and her gait became staggering. She had suffered obstipation for at least eight days. Physical examination at the time of admission revealed bilateral senile cataracts. The heart was slightly enlarged to percussion. The heart sounds were forceful, with a slightly accentuated second aortic sound. A short harsh systolic blow was described at the apex but was not transmitted. Blood pressure was 180/75. There was noticeable tremor of the hands. Deep tendon reflexes were sluggish throughout. The abdomen was soft; no masses or organs were palpable. The remainder of the physical examination was non-contributory. Blood studies showed hemoglobin 88 per cent; leukocytes 10, 650, with a normal differential count; sedimentation rate 40. One stool specimen was negative for blood. Gastric analysis showed no free hydrochloric acid, but there was a response to histamine injection. An electrocardiogram indicated a sinus tachycardia with abnormal P waves, pointing to left heart strain. Roentgen examination of the chest was interpreted as showing slight enlargement of the heart shadow to the left with accentuation of the vascular markings in both lung fields and calcification of the cartilaginous rings of the trachea and of the main bronchi. Roentgenographic studies of the skull were negative. The patient was placed on bed rest and parenteral feedings. On the second hospital day her mental attitude improved. She became more alert and oriented in all spheres and was able to take a liquid diet. However, an attempt to force fluids by mouth resulted in nausea, vomiting, and abdominal distention. As part of a gastro-intestinal investigation and because of the obstipation, a barium enema was given on Sept. 5, 1950.