Two Cases of Barium Fecaliths CPT Richard B.Birrer, MD, MC, USAF* Complicating UGI Series

Though a rare entity, the author experienced two cases. One case was due to inadequate hydration, the other to opiate usage. Both cases were avoidable had proper instructions been given to patients.

Since its introduction in 1896 by Cannon, barium Dr. Birrer received his MD de- sulfate has been the safest and most common diagnostic gree from Cornell University contrast agent in usage. Of the 25,000,000 gastro- Medical College in 1975 and intestinal (GI) barium examinations performed in 1977 did hisresidency infamily med- less than 0.01% resulted in complications, these being icine at the Hunterdon Medical almost exclusively secondary to technological error or to center, Flemington, NJ. He 1 underlying disease. entered the United States Air Barium is essentially an ideal material for diagnostic Force after his internship in contrast studies because it is chemically inert, essentially 1976 and served as the Family 2 insoluble, and nontoxic to the intestinal mucosa. Medicine Specialist in Athens, Reported complications include perforation (only 64 Greece. He hasa biweekly radio cases in the world's literature before 1965), usually program on informative and secondary to underlying disease, aspiration occurring preventive medicine. typically in the very young or old, granuloma formation, CPT Richard B.Birrer, MD, MC, peritonitis and appendicitis, allergic reactions, septicemia, USAF embolization, intravasation, and compaction forma- tion.3-7 habits. He worked long hours as a postal clerk. His Under normal conditions feces are made up of physical examination was unremarkable. Medications approximately 25% solids and 75% water by weight. If a included codeine phosphate for periodic migraine head- barium suspension is added the percentage of solids is aches. An upper gastrointestinal series was performed increased thus enhancing the chance for compaction which demonstrated a small duodenal ulcer. He was formation. placed on heavy regimens of antacid (Maalox). He returned two weeks later complaining of left lower Case 1 quadrant abdominal pain, tenesmus, and constipation. A A 68-year-old white woman presented with epi- rectal examination was negative, though a flat abdominal gastric cramping associated with gas and constipation for film demonstrated a large 5 cmxl2 cm radiopaque con- six months. There was no history of hematemesis, gall cretion at the rectosigmoid junction. Lactulose was bladder disease, postprandial relief, peptic disease, or administered but after 48 hours of no improvement an liver disease, although she admitted to occasional heart- uncomplicated proctosigmoidoscopic removal of the burn and retrosternal chest pains when reclining. The concretion was performed. He did well postoperatively. physical examination was unremarkable. An upper gastrointestinal (UGI) series was per- DISCUSSION formed. This did not demonstrate any ulcer disease, In reviewing Case 1 it was found that the patient left hiatal hernia, or small bowel pathology though there was for a tropical climate shortly after the procedure was some spasm in the jejunum and ileum. She was placed on performed. She had a presumed viral gastroenteritis antacids (Maalox) and antispasmodics and did well until during her vacation. Her constipation symptoms began one month post-UGI when she presented with con- shortly thereafter. In retrospect the barium fecalith stipation, tenesmus, and lower abdominal pain for impaction was promoted by her dehydration during her several weeks. A nontender solid mass was felt on rectal illness in addition to her history of chronic constipation. examination and a flat abdominal film showed a The man in Case 2 suffered an exacerbation of his radiopaque elliptical lesion 4cm x 9cm. The diagnosis of headaches shortly after his UGI for which he took one a barium fecalith was made and she was treated with codeine tablet every four hours for two days. He did not lactulose. She spontaneously passed a fragmented mass become dehydrated during that time. A common com- of feces and barium the following day. plication of opiate usage is diminished bowel motility with increased water absorption. Consequently, a Case 2 colonic barium fecalith formed. A 48-year-old black man presented with progres- sively severe epigastric pains associated with some SUMMARY postprandial relief. He had no history of hematemesis, Two cases of barium fecaliths complicating UGI melena, liver or peptic disease, colitis or change in bowel series are reported. Though a rare entity, one case was due to inadequate hydration, the other to opiate usage. *Formerly with the Air Force in Greece; now in private practice Both cases were avoidable had proper instructions been at the Downstate Medical Center, New York. given the patient. What was a minor inconvenience could

Vol 36, No. 6, November/December 1979 15 have become a major complication requiring surgery. 4. Foti M: Experience gained from a case of peritonitis caused by barium. Orv Hetil 106:845-847, 1965. REFERENCES 5. Killingback M: Acute large bowel obstruction pre- 1. Weigen JF, Thomas SF: Complications of Diagnostic cipitated by barium x-ray examination. Med J Aust Radiology. Illinois, Thomas Pub, 1973, pp 335-376. 2:503-504, 1964. 2. Miller RE, Skucas J: Radiographic Contrast Agents. 6. Larsen E: Barium enema complications. JAMA Maryland, Univ Park Press, 1977, pp 3-195. 229:639-640, Aug 1974. 3. Borden A, Hermel M: Barium fecaliths following 7. Prout BJ: Colonic retention of barium in the elderly gastrointestinal radiography. Am J Gastroenterol after barium meal examination and its treatment 32:573-575, 1959. with lactulose. Br MedJ 4:530-539, Dec 1972.

Veterinary Case Report CPT Nancy K.Jaax, VC*

History A 6-year-old intact male military working dog was presented with the complaint that he had vomited twice in the past 30 minutes. He had been fed his normal ration an hour previously, and kennel personnel noticed his vomit- ing attempts while they were removing feed pans from the area. Concerned because the animal appeared abnormally restless, they presented him for veterinary examination. Physical Examination On physical examination the pulse rate was 80 per minute, temperature 101.5 F, with normal perfusion, and normal mucus membrane color. The abdomen was tense, and auscultation revealed moderate borborygmus. How- ever, no appreciable abdominal swelling was present. A tentative differential diagnosis of either early gastric dilita- tion or high foreign body obstruction was made, and radiographs were obtained. Radiological Data The stomach showed excessive ingesta interspersed with gas, and gastric dilitation in the early stages (Fig 1). This case was unusual in several aspects: (1) Abdominal bloat was not apparent at the time the animal was presented. Usually the diagnosis of gastric dilitation does not require radiological confirmation. (2) This animal had no history of physical exercise immediately prior or subsequent to feeding. (3) The animal had been maintained on MSD, the standard low fiber diet fed to military working dogs, for __ll._ two years without any previous problems. The stomach was decompressed via stomach tube. Nearly 21/2 quarts of ingesta were removed. The dilita- Figure 1. Dog stomach. tion was attributed to heavy overfeeding coupled with voluminous water intake. The recovery was uneventful.

*0IC, Animal Medicine Branch, Ft. Leavenworth, Kansas.

16 Medical Bulletin of the US Army, Europe