97

“Contrast Indicating Digestive

Bubble”: A Sign Perforation of the Tract .

Louis

and Michael

Cipel1

T. Gyepest

.‘...

Bubble formation outside the digestive tract that correlated with small perforations was observed in two Infants during water-soluble contrast material studies using a 50% solution of Gastrografin in water. The causes of extraluminal bubbles are discussed; In

American Journal of Roentgenology 1979.133:97-101.

vitro experiments demonstrated the mechanism of formation and the radiographic characteristics of the various types of bubbles. Extraluminal bubbles appearing during a water-soluble contrast material examination actually represent contrast bubbles. The radiographic density of the bubble walls varies. When the bubbles are small and diluted contrast material is used, it is not possible to detect the presence of contrast material radiographically. Contrast material bubbles are likely to be observed only if a low surface tension contrast agent is used, such as Gastrografin (full- or half-strength in water). Extraluminal contrast material bubble formation may identify and localize a small perforation of the gut when other findings are inconclusive.

In some cases of perforation of hollow viscera, findings may be inconclusive. In such circumstances, material

may

extravasation tion,

contrast establish bubbles.

Received January 20, revision March 9, 1979. 1

Department

fornia

90024.

School

of Radiology, of Medicine,

Address

Department pital Medical

1 978;

reprint

Los

University Angeles,

requests

of Pediatric Radiology, Center, 2801 Atlantic

Beach, California AJR 133:97-101, © 1979 American 0361 -803X/79/1

accepted

after

of CaliCalifornia

to M. T. Gyepes, Memorial Avenue,

90801.

July 1979 Roentgen Ray Society 331 -009.7 $00.00

HosLong

indicated.

The medium

bubble

formation

we observed

on an infant infant with

sign

be

of contrast

with esophageal gastric perforation.

site occurs.

of

perforation While

in the chest

perforation, A 50%

the clinical examination may

looking during

be

for

and plain film with contrast demonstrated

contrast

an esophagram

and in the abdominal solution of Gastrografin

if

extravasaperformed

cavity of another was used as

agent in both cases. In vitro experiments were then performed to the mechanism of formation and radiographic characteristics of the We believe extraluminal contrast bubble formation is a potentially helpful

in the

diagnosis

Case

Reports

Case

1

of small

perforations

of the

digestive

tract.

S. J. , a full term boy from an uncomplicated pregnancy, had dextroversion, ventricular septal defect, nonrotation of the midgut, and eventration of the left hemidiaphragm. A radionuclide scan showed a normal spleen. At age 5 weeks, the patient was admitted in acute distress. A pneumoperitoneum was recognized, but surgery was refused by the parents. With supportive measures (antibiotics, oxygen, isuprel infusion, intravenous alimentation, and gastric suction), the baby did remarkably well. Six days after admission (age 6 weeks), plain films showed resolution of the pneumoperitoneum and the presence of a large pouch containing air and fluid located just caudal to the stomach. Contrast material (20 ml) of 50% Gastrografin and 50% 05W was injected through a nasogastric tube under fluoroscopic control. Extravasation of contrast material was apparent after 5 mm (fig. 1 A) and bubbles were seen in the same area about 5 mm later (fig. 1 B). Irregularity of the greater curvature and posterior aspect of the stomach was attributed to edema and local inflammation. The parents then consented to surgery. A preoperative gastroscopy demonstrated 2 areas of well circumscribed minor bleeding on the greater curvature, but

American Journal of Roentgenology 1979.133:97-101.

98

CIPEL

Fig.

1 -Case

1.

A,

Extravasation

of contrast

material

AND

on early

(arrow)

film.

GYEPES

B, Small

AJR:133,

(arrow)

bubbles

close

to stomach

and away

from

small

July 1979

bowel

loops

(arrowheads).

no

definite

ulcer.

At

straw-colored fluid removed. No gastric

laparotomy,

a cystlike

structure

containing

adhered to the stomach and colon and was perforation was visible. The pathologic exam-

ination

was

course

was uneventful.

consistent

with

a walled-off

abscess.

The

postoperative

diagnosis

Case 2 0. G., a 2.98 kg product of a 41 week gestation, had esophageal atresia with blind upper pouch and tracheal fistula of the lower segment. On day 2 esophageal anastomosis, closure of the trachea, and gastrostomy were performed and a right chest tube was placed. An esophagram at age 1 0 days demonstrated slight narrowing of the anastomosis, attributed to postoperative edema, and gastroesophageal reflux. There was no evidence of holdup of contrast material or leakage. Oral feeding was well tolerated. Two routine esophageal dilatations were performed, the first 3 weeks after operation

(String

tolerated, evening

and

and

Tucker

the second

of the

second

1

dilatation,

dilator,

size

22)

week later (dilator the

patient

which

was

size 26). On the

refused

his

because

complete

healing

of the

esophageal

anastomosis

of

esophageal

perforation

was

made

and

was 50% small The

subsequently

confirmed by a second, more forceful infection (fig. 3B). A chest tube was inserted. Purulent fluid was removed from the right hemithorax; culture was positive for Kiebsiella pneumoniae, Streptococcus veridans, Lactobacillus species, and Pseudomonas maltophilia. Blood culture was also positive for Klebsiella. Treatment consisted of antibiotics, oxygen and hyperalimentation. The patient eventually recovered. An esophagram performed under fluoroscopic control 3 weeks after admission (age 7 weeks) showed no leak at the site of anastomosis.

Materials

and Methods

well

feeding.

The next day the patient was admitted with the diagnosis of septic shock. Radiographs showed several large lucencies in the right chest, some of which contained fluid levels (fig. 2A). The clinical impression was that of necrotizing pulmonary infection

mediastinal inflammation (fig. 2B). A bedside esophagram performed. Contrast material made of 50% Gastrografin and D5W was injected through a nasoesophageal tube; a few bubbles were demonstrated in the right upper chest (fig. 3A).

was

assumed 4 weeks after surgery and the esophageal dilatation seemed to be uncomplicated. However increased separation of the trachea from the esophagus on the lateral view was suspicious for

To investigate

the formation

of extraluminal

bubbles

during

water-

soluble contrast material examinations in these two patients, in vitro experiments were undertaken. Several contrast agents were tested for bubble formation (Gastrografin, a 50% solution of Gastrografin in water,

Hypaque

50%,

and

Reno-M-60).

Air (1 0 ml) and

a contrast

agent (5 ml) were introduced through a catheter to inflate small rubber bags. These bags were radiographed in air or while immersed in water. Radiographs and observations were made with intact relative

bags

and

to the

with position

pinhole of the

or slit contrast

perforations material.

in various

locations

AJR:133,

July

1979

Fig. 2.-Case

CONTRAST

2. Anteroposterior

(A)

and lateral (B) chestfilms simulating rotizing pneumonitis. Increased between esophagus and trachea

American Journal of Roentgenology 1979.133:97-101.

on lateral surgical.

view.

Rib

changes

99

BUBBLE

necspace visible

are

post-

Fig. 3.-Case 2. A, During first injection of contrast material. Small bubbles occurred in right upper chest. No definite area of increased density. B, Perforation demonstrated by second more forceful should

injection. be higher.

Ideally,

tip

of

tube

Results Various

amounts

bags

immediately

most

numerous

of

bubbles

after when

filling.

were

air was

agents, and when Gastrografin used. The inside bubbles were

and

especially

Reno-M-60

the contrast

agents

‘

‘inside’

injected

trast was when

observed

These

were were

‘

rapidly

within bubbles into

the

the were

the

con-

surface

with

formed

at the

(full- and half-strength) fewest when Hypaque used,

injected

and

were

slowly

into

pended

bags

were

absent air-filled

#{149}When the bags

filled

in air were

with punctured

air and

contrast

with

a metal

agent pin.

and

Puncture

preliminarily contrast

rotated

material

outer

aspect

to entirely

and of

then

the

coat

the

punctured,

hole.

inner

bubbles

Thus,

‘

‘outside”

bubbles were observed when the hole was made at the interface of the air and contrast agent (fig. 4A), or when the hole was brought to that interface by rotating the bags.

bags. Rubber

the upper part of the bags caused an air leak, and puncture of the lower part caused a fluid leak. In these two circumstances, no bubbles were observed outside of the bags. If

susof

bags

were

lower

to the upper

(full-

or half-strength)

rotated

aspect was

to bring

the

puncture

of the bag, and when used,

outside

bubble

from

Gastrografin formation

the

100

CIPEL

AND

GYEPES

AJR:133,

TABLE Surface

Tension

Agents Ten sion

(dynes/cm)

Agent undiluted

50% solution

Gastrografin Hypaque 50%

41 50

42 55

Reno-M-60

57

65

Water

75

or 05W

Note-A 6 cm platinum-iridium 70535) for measurements (Central

taming

only

air was

ring

(no.

..

70542)

was

Co.

Chicago,

Scientific

pierced.

by film of Gastrografin the outside bubbles

.

When

attached

to the tensiometer

an area

of a bag

(full- or half-strength) that formed and escaped

4.-A,

American Journal of Roentgenology 1979.133:97-101.

Bubble formation

outside bag (arrow) after puncture near Gastrografin. Arrowhead indicates ‘ ‘inside’ ‘ bubble. B, Floating ‘ ‘outside’ ‘ bubble formation after puncture of bag immersed in water (puncture hole about 1 cm below water surface, half-strength Gastrografin). C, ‘ ‘Outside’ ‘ bubble floating on water (puncture hole about 1 cm above water, half-strength Gastrografin). Fig.

surface

of undiluted

coated

was punctured, to the surface

for

some

time

after

the

hole

was

above

the

Outside bubbles were smaller, more numerous, stable when Gastrografin (full- or half-strength) The outside bubbles obtained with Hypaque 50% M-60 were larger, fewer, The bubbles obtained strength) grafin.

had a light Radiographs

agent

in the

walls

yellowish confirmed

hue characteristic the presence

of these

bubbles,

density of the smaller bubbles when half-strength Gastrografin The duration of ‘ ‘Gastrografin’ pended diameter, bubbles not

and

that

the

change

in

number

or

half-

Contrast

agent

either

empty,

been

punctured

observed contrast air-filled

only agent; bags

The

with

immersed

in

filled

the

a metal

pin.

wall

bubbles

had were

covered by a film of of the injection into dependant area, or the puncture site. when the contrast

perforation. When

were the

repeated

upper

with

the

(air-containing

and

bubbles

number

when

a bag

bags and

con-

from

findings immersed

the water,

a puncture

were identical bag.

bubbles

that

that

had

extradigestive

two cases were not liquid milieu (water scess bubbles). The with contrast material delayed

films

Consequently,

they

in an

immersed

to those

observed

with a 5-mminstead of a observed only

disappeared.

bubbles

may

(2

hr

their

due to mere bubbles) or

be due

due

to increased

formed

during

extravasation into viscous

of air into a material (ab-

bubbles formed during examinations and were not visible on the scout and film

in case

timing

was

pressure

1 , 6 hr

different

provoked

the contrast

studies

In case 1 , the amount injected was moderate (20

after

film

from

in case

that

injection.

by the seems

In case

2).

of extravthe conthese exof air

injections

per-

unlikely.

of contrast material ml), the films clearly

was not distended, the baby was turned the

to gas

abscess [1 ]. Our bubbles in our

asation of air, since this was demonstrated before trast examinations and probably continued after aminations were completed. Sudden extravasation

mm

observed

above

trapped within the pasty material of an observations suggest that the extraluminal

ments).

were

formed

Discussion

the stomach only when

bubbles

bubbles

formed

of inside

non-contrast coated) part of a bag was punctured, outside bubbles formed and went up to the surface. These water bubbles were relatively large, few, and unstable (they all disappeared before a film could be taken in our experiIdentical

outside

of a bag, the a completely

It is known if

that were and

with

when the bags contained bubbles prior to the incision. The number of outside bubbles formed corresponded to the

when even

air (1 0 mg)

Outside

of the fluid reached formation stopped

experiments water.

slightly occurred

into bags

with

when the puncture was that is, at the beginning punctured in their most

overflowed preceding

decreased

(5 ml) was introduced

or preliminarily

when the upper limit The outside bubble agent

only

obtained

The preceding experiments were repeated long incision in the bag made with scissors pinhole puncture. Outside bubbles were

did not appear increased was used (figs. 4B and 4C). ‘ bubbles varied and de-

Outside bubbles inside bubbles.

used

part with

mainly on bubble size (up to 5 mm when 1 -2 mm in up to 2 hr when 0.5-1 mm in diameter). The inside were much larger than the puncture hole and did

outside bubbles formed. the bags did not contain

bubbles

trografin. These bubbles burst in seconds. The preceding experiments were repeated with the bags floating on water. When Gastrografin (full- or half-strength)

outside

of Gastroof contrast

except

outside

flowed down the outer aspect of the bag until they reached the water and remained at its surface (fig. 4C). When Hypaque 50% and Reno-M-60 were used, the bubbles usually burst and disappeared before reaching the water. When

fluid

and more was used. and Reno-

and burst in seconds. with Gastrografin (full-

The

more similar

Hypaque 50% and Reno-M-60 were larger, fewer, and less stable than those obtained with diluted and undiluted Gas-

was continued level.

of Gastrografin.

(no.

Ill.).

were different from water bubbles. They were smaller, numerous, more stable, and had a light yellowish hue to that

1979

1

of Contrast Surface

Contrast

July

that show

was that

and the bubbles occurred to the supine position 10 2, bubbles

were

observed

AJR:133,

after

CONTRAST

July 1979

the

first

injection

(slow),

and

no

new

bubbles

hr since

they

bubbles therefore, are our

are

formed, cases.

served

trapped

in case

viscous

material.

The

usually density

1 suggests

the

presence

of contrast

the

dilution

vitro

data

of the

the extradigestive Our

agent

as

and

Thus,

because

bubbles

represent

agent

bubbles

through

through

a large

was

small,

and

body

were observed gastric body contrast beginning agent

were

the

that

either

bubbling

a small

hole,

the bubble, tension, R the surface

filled

that

with

of

a film

contrast

in which

we

force

to a given as:

F

length

2La

=

(F

force,

L

lower

and

the

Contrast bubbles are theoretically Gastrografin, since it contains 80) and has the surface

a very tension

bubbles

low surface of a 50%

occur

in our

two

clinical

more

confirmed

best a wethng

grafin in water is only slightly higher Gastrografin, and bubble formation did

are

was

of a

a

stable by our

demonstrated agent (Poly-

tension solution

(table 1). of Gastro-

than that of undiluted was abundant expericases

using

Therefore,

diluted

Gastrografin. The bubbles produced experimentally with diluted Gastrografin were well visible, although their walls were less dense than with undiluted Gastrografin. Therefore, half-strength Gastrografin may be preferred to undiluted

after

the

of such

procedure

of [5];

a complication

with

If a perforation

and

water-soluble

contrast

is suspected, agents

of contrast

studies

perforaor air and

are

often

of contrast barium

should

material

observation

resemble of air,

as a pneumoperitothat do not require

extravasation

is not

for the formation

most likely

represent

mdi-

material

is contraindicated

be used

[9].

always

Since

of extraluminal

contrast

extrav-

demonstrated, bubbles

Our clinical and experimental bubbles that appear during

Low

surface

bles.

tension

Therefore,

agent,

the

data show a contrast

medium

formation

We

Gastrografin,

and

of Gastrografmn,

is recommended

perforation. undiluted

favors use

We thank Dr. P. Spiegler R. Rose for his suggestions.

difference across the (p pressure inside

This

Gas-

bubbling

when

prefer

stability which

looking

a

for a gastroin-

half-strength

as it seems

of bubcontains

Gastrografin

safer.

ACKNOWLEDGEMENTS

= pressure outside the bubble, a = surface diameter of the bubble) [2]. Therefore, when tension is low, the surface force and the pres-

are

[6,

[8].

testinal

extra-

length,

=

7].

over

in which obtained

surface

necrosis

diluted

to the hyperosmolarby careful hydration

cavity, as well by conditions

to demonstrate

wetting

po =

difference

and

of the =

[2]. The pressure is: p - po = 4a/R

those was

bowel

not with

through a small perforation. Increased density in the bubble walls may be visible, but it may be absent particularly when the bubbles are small and a diluted contrast agent is used.

esophagus

observed

clinically were similar to a film of contrast material

surgery

examination

bubbles

the

the pleural be produced

should be made. that extraluminal

the

and

risk

and

but

conditions that might tract. The presence

fluid, within neum, may

careful

occurred at the a film of contrast

and

hemorrhage undiluted

during,

is less

of

phenom-

material;

there

of

extravasation

the former

perforation,

and more likely to be observed. in vitro experiments.

me.tally

out

before,

There are many of the digestive

asation

con-

In our two cases,

it seems

the

is expressed

sorbate However,

likely

extraluminal

or

perforation.

circumstances

bubbles out of

surface tension) surface of a bubble

with

most

local with

Gastrografin.

cated

air, either because the esophagus was spontafilled with air (fig. 2) or because air was inadvertently (no special care was taken to avoid injection of air).

=

sure

in

timing,

In case 1 , extravasation of contrast in the prone position when the gastric

covering

experimentally. The surface bubble

indicate

agent. In case 2, bubbles probably of the first injection (slow), while

Therefore, luminal bubbling

clinically

our

patient

diluted tion

seen and

by

of their

since observed

however,

in the supine position when the antrum and were filled with air and coated by a film of

was

contained neously injected

suggested

we observed

and

enon was the cause. material was observed antrum

the

bubbles.

observations

contrast perforation

4C).

bubbles

contrast

in vitro

trast

contrast

4B

and, they

material.

of the bubble walls size of the bubbles

been

trografin [3, 4] Dehydration secondary ity of Gastrografin can be avoided

larger than those seen in in the bubble walls ob-

The absence of increased density in case 2 may be due to the small (figs.

has

water

in vitro (1 burst very quickly be seen on films taken just after

and (2) were The increased

represented

American Journal of Roentgenology 1979.133:97-101.

within

bubbles in 2-6

)

we obtained can only

101

Gastrografin,

were

seen after the second injection (forceful). Gas trapped within an abscess are unlikely to disappear

BUBBLE

for providing

a tensiometer

and Dr. 0.

REFERENCES 1 . Nelson SW: Extraluminal gas collections due to diseases of the gastrointestinal tract. AJR 1 1 5 : 225-248, 1972 2. Sears FW, Zemansky MW: University Physics, 2d ed. Reading, Addison-Wesley, 1 955, pp 224-229 3. Leonidas JC, Burry VF, Fellows RA, Beatty EC: Possible adverse effect of methylglucamin diatrizoate compounds on the bowel of newborn infants with meconium ileus. Radiology 1 21: 693-696, 1976 4. Gallitano AL, Kondi ES, Phillips E, Ferris E: Near-fatal hemorrhage following gastrografin studies. Radiology 1 1 8 : 35-36, 1976 5. Rowe Ml, Furst AJ, Altman DM, Poule CA: Neonatal response to gastrografin enema. Pediatrics 69 : 29-35, 1971 6. Felson B: Abdominal gas: a roentgen approach. Ann NY Acad Scil5O:141-161, 1968 7. Fraser RG, Pare JAP: Diagnosis of Diseases of the Chest, vol 1. Philadelphia, Saunders, 1970, pp 518-541 8. Frimann-Dahl J: Roentgen Examinations in Acute Abdominal Diseases, 3d ed. Springfield, Thomas, 1 974, pp 423-430 9. Almond CH, Cochran DQ, Shacart WA: Comparative study of the eftects of the various radiographic contrast media in the peritoneal cavity. Ann Surg 1 54 : 21 9-224, 1961