The sequelae of barium aspiration

Abstract

A 67-year-old gentleman of Chinese ethnicity presented with a 6-month history of worsening dysphagia, initially with solids, followed by liquids, resulting in poor oral intake. He denies coughing or choking while swallowing. He smoked 20-pack years of cigarettes and stopped 6 months prior to presentation. There was significant weight loss of 30 kg in 6 months associated with lethargy.An oesophagodeudonoscopy at the fourth month revealed mild oesophagitis with a grade three (Type I) hiatus hernia. He was treated with proton pump inhibitors, but the dysphagia worsened. A flexible laryngoscopy revealed unremarkable true and false cords, with no pooling of saliva or evidence of aspiration. He underwent a barium swallow to rule out a mechanical cause.During the barium swallow, he was aspirating silently, with significant amounts of barium contrast in his right bronchus (Fig. 1). The study was halted immediately, and the patient was propped up, with vigorous suctioning. There was no evidence of oxygen desaturation.

Unexpected Barium Aspiration

“…Complications vary from hypoxia, respiratory failure, secondary aspiration pneumonia, shock, and acute respiration distress syndrome. 1,2 The highest dose of barium associated with aspiration mortality was seen with Gray el al 7 at 250% weight/volume. The current recommended barium concentration for barium studies is 100 g barium in every 100 ml of solution.…”

“…However, other studies caution against bronchoalveolar lavage to avoid further distribution of barium. 2,6 As barium can be visualized on radiograph, the timing of when it is cleared can vary. For our patient, his chest radiograph 3 months later still showed barium, although it was improved.…”

“…1 This particular aspiration poses several pulmonary complications and has a varying prognosis. 1,2 We present a case of barium aspiration to the right middle lobe with residual contrast present in the lung 3 months later.…”

Barium Contrast Aspiration

“…Barium sulfate aspiration is a rare cause of clinically significant pulmonary disease. [1][2][3] Risk factors for barium contrast aspiration include advanced age, [1][2][3] known oropharyngeal dysphagia, 3 head and neck cancers, 3 and vomiting. 2 Management includes supportive care with oxygen and chest physiotherapy.…”

“…2 Bronchoscopy with suction may be used with caution in severe cases; however, there is risk of seeding of contrast throughout the bronchial tree. 1,2 (doi:10.7556/ jaoa.2019.097)…”