Perforation of the rectum and sigmoid colon during barium-enema examination

Abstract

Perforation of the rectum or sigmoid colon complicated 5 of 2200 barium-enema examinations performed during a 4-year period. Three patients with rectal perforations manifested by air extravasation were successfully treated with intravenous antibiotics and complete bowel rest. Two patients with barium extravasation were treated with immediate operation and colostomy. All five patients recovered. Perforation was found to be associated with a rectal stricture due to ulcerative colitis, a rectal cancer, an incarcerated inguinal hernia, fulminant ulcerative colitis, and a normal colon in an elderly patient. To determine the pressure in the rectum that could potentially be generated during a barium-enema examination, the pressures created by a standard barium delivery set were measured, using 1-meter columns of water, 25 percent diatrizoate sodium (Hypaque), 20 percent barium, and 80 percent barium. The columns generated pressures of 70, 85, 95, and 120 mm Hg respectively. Squeezing the delivery bag increased the pressure 21 to 79 percent or a maximum of 55 mm Hg. Colorectal perforation during barium-enema examination that was not accompanied by barium extravasation could be successfully treated nonoperatively. The associated pathology and our studies of pressures generated during a barium-enema examination allow us to suggest that the incidence of colorectal perforation during barium-enema radiography can be reduced by 1) performing proctoscopy prior to barium enema, 2) avoiding the use of the rectal balloon in patients with known rectal lesions, 3) avoiding barium studies in patients with active colitis, 4) avoiding generation of pressure greater than that created by a column of barium suspension of one meter, and 5) using a lower concentration of barium when possible.

Retroperitoneal perforation of the rectum during double-contrast barium-enema examination: a life-threatening complication

“…Terranova et al 3 reported that this complication occurred in 1% of all barium studies. In the study of Fry et al 4 rectum or sigmoid colon perforations were found in 5 cases among the 2200 barium-enema examinations performed during a 4-year period.…”

The safety of same‐day CT colonography following incomplete colonoscopy with polypectomy

“…[35][36][37] Barium enema pressures of around 40 mmHg are necessary to perform an adequate double contrast study. 20,22,38 Human studies have shown that the luminal pressure needed to perforate the colon is higher than that: lowest in the cecum, and highest in the rectum. The risk increases with biopsies that involve the muscularis propria, which is unusual for routine biopsies.…”

“…2,3 The rate of colon perforation for colonoscopy is 0.03 to 1% for diagnostic and 0.2% for therapeutic procedures with 0.0009% mortality, and 0.02 to 0.24% for DCBE with 0.07% mortality. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] A recent metaanalysis by Bellini et al of the rate of CTC perforation in 103,399 patients indicates a perforation rate of 0.04% (95% confidence interval (CI) 0-0.10; I 2 ¼ 29.1%) or one in 2500 studies. 19 Some centers wait days to perform a DCBE following an incomplete colonoscopy with biopsy because of concerns about causing a perforation as a result of the pneumatic pressure and resultant tension on the colon wall from the injection of barium, even though data to support this concern are not robust.…”

Iatrogenic colorectal perforation induced by anorectal manometry: Report of two cases after restorative proctectomy for distal rectal cancer

“…In treatment of iatrogenic colonic perforation, nonoperative management of colonic perforation is advocated for patients who are clinically stable with no evidence of peritonitis [8][9][10] . For selected patients with incidental intramural or small retroperitoneal perforations but no evidence of barium spillage, favorable results have also been reported as the result of conservative treatment consisting of bowel rest combined with total parenteral nutrition, intravenous fluid treatment, and broad-spectrum antibiotics [11,12] .…”