Complications agnostic barium gravest
and
of mild to severe degree examinations have been
rarest
being
16 cases of barium study,
eight
venous
dithe
In a review
of
intravasation.
embolization
of 10 patients
associated with reported (3-10),
during
with
a
age
of 72 years
died of embolization into the systemic circulation, while one of six patients with an average age of 43 years died of embolization into the portal circulation (3). Perforation of the intestine by feeding kinds has been reported, as has perforation
for small volved
bowel
enema
perforation
of the
tubes
of various
during intubation (10). The majority of the cases in-
study
duodenum
by the
distal
end
of the
tube in newborns. This has been attributed to the stiffening of the polyvinyl tubes after 1 or more days of retention in the intestinal lumen (7). In a review of 106 cases of hypersensitivity reactions after barium studies of the upper and lower gastrointestinal tract, it was found that 65 cases involved the skin, nine were respiratory in nature, nine involved loss of consciousness, one was associated with an extraordinary migraine headache, and 22 were unclassified (6). One report implicated one of the many additives as the probable cause of the hypersensitivity reaction (9), while glucagon was thought to be the causative agent in another study (5). A fatal anaphylactoid reaction occurred in a 43-year-old woman with an extensive history of allergy after a single-contrast barium enema study (8). Autopsy showed severe mucous plugging
of the
and
em-
physema. The colon was thoroughly examined at autopsy was intrinsically normal. There were no tears or perforations
and
evident
in
bronchi,
the
as well
as pulmonary
edema
mucosa.
Increased density of the liver, spleen, and spine after intravasation of barium has been reported in a 36-year-old woman (4). Deposition of barium sulfate particles in the reticuloendothelial cells is responsible for the uniformly high density in these organs at radiographic study. It is thought that the mitial homogeneous hyperdensity of the liver and spleen will decrease with time as some of the barium sulfate slowly migrates to the lymphatic system. Survival depends on the amount and the speed of barium intravasation and on the age and general health of the patient; all patients aged less than 40 years
have
survived
(4).
To summarize, systemic occur in the gastrointestinal tons
(eg,
ulceration,
venous
intravasation
tract
of
can
barium
without predisposing and can cause both
inflammation)
facfatal
ity.
A, Hamza Radiology 1989;
2.
Berdon
3.
Fowlie
4.
Chart
WE.
Reply.
diographic
1989;
LC, Ngan
H.
Barium
in a nonfatal
intravasation:
ra-
case: Radiology
1987;
163:211-212.
Gelfand phylactic glucagon
6.
Janower ML. Hypersensitivity reactions after barium the upper and lower gastrointestinal tract. Radiology
DW, Sawers JC, Deponte KA, Summer TE, Ott DJ. Anaand allergic reactions during double contrast studies: is or barium suspension the allergen? AJR 1985; 144:405-
406.
studies 1986;
161:139-140.
7.
Myers
8.
cations. New York: Springer, Fecko PJ, Simms SM, Bakirci
1981; 78. N. Fatal hypersensitivity
during
a barium
1989;
Schwartz
EE,
9.
tivity reactions 143:103-104.
896
Radiology
#{149}
Glick
GG.
SN,
during
Radiology
intubation
for small
1988; 168:39-41.
of Renal
Trauma
MD,* Morris Schoeneman, MD,t and Howard Finestone, MD* and Nephrology,t Beth Israel
Center
Avenue
and
16th
Street,
New
York,
NY 10003
Editor:
and benefited greatly from the article by Drs PolWein (1), which appeared in the August 1989 issue of Radiology, but we wish to offer an alternative view regarding the role of scintigraphy. The authors remark that “earlier proponents of scintigraphy acknowledge the dominant role now played by [computed tomography].” Their reference is to a single article, which appeared in 1985 (2). Since then, improvements in instrumentation, notably single photon emission computed tomography (SPECT) and the development of lack
and
new
radiopharmaceuticals,
toacetyltriglycine
(MAG3),
such
as technetium-99m
have
enhanced
the
mercaprole
of nuclear
imaging in detecting renal trauma (3,4). Studies comparing scmntigraphy with excretory urography have shown that Tc99m dimercaptosuccinate and Tc-99m glucoheptonate more accurately display parenchymal defects while demonstrating significant degrees of extravasation (5,6). Renal perfusion and functional compromise are better demonstrated with scintigraphy than with any other available noninvasive imaging study. Tc-99m MAG3, currently in widespread use outside the United States, provides high-resolution images even in cornpromised kidneys. Of all available imaging modalities, scmtigraphy is least dependent on patient preparation and cooperation and may be performed in the emergency department or intensive care unit. Nuclear imaging, especially if com-
bined
with
sonography,
ation as an attractive tory urography.
deserves
more
alternative
frequent
to the
more
consider-
invasive
excre-
References 1.
3.
Pollack HM, Wein AJ. Imaging of renal 172:297-308. Waxman J, Belman B, Kass EJ. Traumatic lower renal pole in children. J Urol 1985; Van Heertu.m RL, Brunetti JC, Yudd AP. ing. Semin Nucl Med 1987; 17:230-246.
trauma.
Radiology
amputation 135:114-1 Abdominal
1989;
of the left 17. SPECT
imag-
4.
Levin K, Keyes JW, Zeissman H, Haukness B. High resolution Tc 99m-DMSA SPECT renal imaging. Presented at the 36th Annual Meeting of the Society of Nuclear Medicine, St Louis, June 15, 1989.
5.
Russell
172:213-214.
5.
enema.
perforation
study.
CD,
Thorstad The
BL,
Dubovsky
EV.
triglycine,
a technetium-labeled
Strutzman
kidney:
gy 1989; 172:427-430. Barasch L. Spontaneous technetium 99m DTPA 10:107-109.
ME,
imaging
Yester
with
analog
MV,
Tc-99m
Fowler
D,
mercaptoacetyl-
of iodohippurate.
perforation of the excretory urography.
ureter Urol
Radiolo-
diagnosed on Radiol 1988;
60:404-406.
Wong
Ghahremani
Duodenal
We enjoyed
GM. Barium embolisation during a report of a case and review of the
and CT findings
MA,
Medical First
6.
Radiology
enema
a Scintigraphy
and sensitiv-
absorption
172:213.
S, Barton JR, Fraser barium enema examination: literature. BrJ Radiol 1987; FL, Tso WK,
sulfate
Barium
HM.
WC.
bowel
From: C. Richard Goldfarb, Fukiat Ongseng, MD,* Departments of Radiology*
2.
and nonfatal reactions. Systemic intravasation carries a high mortality. Younger patients have a better survival rate than older patients. It is not clear whether the barium itself or one of the many additives used is responsible for the various reaclions encountered.
References 1. Ahmed
Diner
enema
barium
an average
10.
AJR Foggs
after barium
latrogenic
MB,
enema
gastrointestinal
complireaction
153:275-276. Silverstein
examination.
GS.
Hypersensi-
AJR 1984;
of
Drs
Poliack
We their the our the
are very
and
Wein
respond:
grateful to Dr Goldfarb and his associates for enlightening comments about the role of scintigraphy in assessment of renal trauma. As we tried to emphasize in review article, there is no right or wrong way to image patient whose kidney is injured. Imaging strategies will vary with many factors, including the resources and the personal preferences of the attending physicians. We were, in fact, rather upbeat about the usefulness of radionuclide imaging of the traumatized kidney, pointing out many of its advantages. Dr Goldfarb and his colleagues further bring to the attention of the readers of Radiology the fact that new instrumentation, such as SPECT, and new radiopharmaceuticals, such
raphy
as Tc-99m
more
MAG3,
informative
may,
and
in
the
more
future,
popular.
make
If this
renal
scintig-
proves
to be
March
1990
the case, few will be displeased. Meanwhile, there are some aspects of radionuclide renal imaging-both old and newthat seem worthy of emphasis: 1. The large body of practical, day-to-day experience requmred before any modality can be accepted into routine clinical use has yet to be accumulated in the cases of SPECT and Tc-99m MAG3 imaging of the injured kidney. 2. Neither SPECT nor Tc-99m MAG3 imaging currently approaches excretory urography in availability, especially during the nonworking day. 3. The anatomical detail, especially of the renal collecting systems and ureters, depicted with excretory urography is superior to that depicted with scintigmaphic techniques.
4. The several-hour parenchymal
age the kidney acute abdominal 5. Not
delay
uptake
from
of most
injection
radiopharmaceuticals
can be a significant trauma.
everyone
would
handicap
to maximal renal used to imin the setting of
agree with the contention that “renal perfusion
of Dr and func-
Coldfarb and his co-workers tional compromise are better than with any other available
demonstrated with scintigraphy noninvasive imaging study.” Certainly, an equally strong case could be made that computed tomography, especially with bolus-administered contrast material, fits this definition just as comfortably. Once again, we thank Dr Goldfarb and his colleagues for their areas
thoughts.
We eagerly
to which
they
await
have
called
further
developments
in the
attention.
Howard M. Pollack, MD,* and Alan J. Wein, MD1 Departments of Radiology* and Surgery,t University Pennsylvania School of Medicine and Hospital 3400 Spruce Street, Philadelphia, PA 19104
of
dilional contrast media are studied, such use may lead to confusion. The drug used in each of the studies cited was gadopentetate dimeglumine, which is the United States Adopted Name (USAN)
for the trademarked
known
Use
From:
Harold
Berlex
Laboratories,
300 Fairfield
of Names
A. Goldstein, Inc Road, Wayne,
for
MR
Contrast
As other
MR contrast
Recently,
several
in which “Cd-DTPA”
the terms
NJ 07470
Volume
174
are described (nonproprietary), (1-7)
articles used
Number
#{149}
containing
different
safety
and
efficacy
active
sub-
names will their various
characteristics.
References 1. Carvlin MJ, Arger PH, Kundel HL, et al. Use of Gd-DTPA and fast gradient-echo and spin-echo MR imaging to demonstrate renal function in the rabbit. Radiology 1989; 170:705-711. 2. Choyke PL, Frank JA, Girton ME, et al. Dynamic Gd-DTPA-enhanced MR imaging of the kidney: experimental results. Radiology 1989; 170:713-720. 3. Elster AD, Moody DM, Bail MR, Laster DW. Is Gd-DTPA required for routine cranial MR imaging? Radiology 1989; 173:231-238. 4. Erlemann R, Reiser MF, Peters PE, et al. Musculoskeletal neoplasms: static and dynamic Gd-DTPA-enhanced MR imaging. Radiology 1989; 171:767-773. 5. Heywang SH, Wolf A, Pruss E, Hilbertz T, Eiermann W, Permanetter W. MR imaging of the breast with Gd-DTPA: use and limitations. Radiology 1989; 171:95-103. 6. Krestin GP, Steinbrich W, Fnedmann G. Adrenal masses: evaluation with fast gradient-echo MR imaging and Gd-DTPA-enhanced dynamic studies. Radiology 1989; 171:675-680. 7.
Yoshida
H, Itai Y, Ohtomo
hepatocellular
Radiology
with
K, Kokubo
carcinoma dynamic
1, Minami
and cavernous
FLASH
MR imaging
(RSNA
‘89 annual
M, Yashiro
hemangioma: with
N.
dif-
Gd-DTPA.
1989; 171:339-342.
Erratum
have
by several specific and brand name appeared
in Radiology,
“gadolinium,” “gadolinium DTPA,” and for the magnetic resonance (MR) imaging contrast medium gadopentetate dimeglumine. While at one lime use of these terms may have been acceptable, as adwere
media
stances are developed, the use of the appropriate be necessary to differentiate the products with
MD
Editor: What’s in a name? Drugs names: chemical, generic or trademark (proprietary).
chemically
dihydrogen
gadolinate (2-) (2:1). This substance is the first and only paramagnetic MR contrast medium commercially available for routine clinical use in the United States.
ferentiation
Appropriate Media
injection,
[N,N-bis[2-[bis(carboxymethyl)aminojethyl]glycinato-(5-)]-
Small
.
Magnevist
as 1-deoxy-1-(methylammno)-D-glucitol
3
Radiology
1989;
173(P):434
program)
Paper 1405, “Use of In-il 1-labeled Nonspecific Polyclonal IgG in Patients with Acute Inflammation or Infectious Processes,” should be amended to include the following authors: Paulo A. Carvalho, MD, Annikke D. Van Den Abbeele, MD, James Maguire, MD, Rebecca A. Aaronson, MA, Amin I. Kassis, PhD, William C. DeSisto, CNMT, Sabah S. Tumeh, MD.
Radiology
#{149} 897
and
of mild to severe degree examinations have been
rarest
being
16 cases of barium study,
eight
venous
dithe
In a review
of
intravasation.
embolization
of 10 patients
associated with reported (3-10),
during
with
a
age
of 72 years
died of embolization into the systemic circulation, while one of six patients with an average age of 43 years died of embolization into the portal circulation (3). Perforation of the intestine by feeding kinds has been reported, as has perforation
for small volved
bowel
enema
perforation
of the
tubes
of various
during intubation (10). The majority of the cases in-
study
duodenum
by the
distal
end
of the
tube in newborns. This has been attributed to the stiffening of the polyvinyl tubes after 1 or more days of retention in the intestinal lumen (7). In a review of 106 cases of hypersensitivity reactions after barium studies of the upper and lower gastrointestinal tract, it was found that 65 cases involved the skin, nine were respiratory in nature, nine involved loss of consciousness, one was associated with an extraordinary migraine headache, and 22 were unclassified (6). One report implicated one of the many additives as the probable cause of the hypersensitivity reaction (9), while glucagon was thought to be the causative agent in another study (5). A fatal anaphylactoid reaction occurred in a 43-year-old woman with an extensive history of allergy after a single-contrast barium enema study (8). Autopsy showed severe mucous plugging
of the
and
em-
physema. The colon was thoroughly examined at autopsy was intrinsically normal. There were no tears or perforations
and
evident
in
bronchi,
the
as well
as pulmonary
edema
mucosa.
Increased density of the liver, spleen, and spine after intravasation of barium has been reported in a 36-year-old woman (4). Deposition of barium sulfate particles in the reticuloendothelial cells is responsible for the uniformly high density in these organs at radiographic study. It is thought that the mitial homogeneous hyperdensity of the liver and spleen will decrease with time as some of the barium sulfate slowly migrates to the lymphatic system. Survival depends on the amount and the speed of barium intravasation and on the age and general health of the patient; all patients aged less than 40 years
have
survived
(4).
To summarize, systemic occur in the gastrointestinal tons
(eg,
ulceration,
venous
intravasation
tract
of
can
barium
without predisposing and can cause both
inflammation)
facfatal
ity.
A, Hamza Radiology 1989;
2.
Berdon
3.
Fowlie
4.
Chart
WE.
Reply.
diographic
1989;
LC, Ngan
H.
Barium
in a nonfatal
intravasation:
ra-
case: Radiology
1987;
163:211-212.
Gelfand phylactic glucagon
6.
Janower ML. Hypersensitivity reactions after barium the upper and lower gastrointestinal tract. Radiology
DW, Sawers JC, Deponte KA, Summer TE, Ott DJ. Anaand allergic reactions during double contrast studies: is or barium suspension the allergen? AJR 1985; 144:405-
406.
studies 1986;
161:139-140.
7.
Myers
8.
cations. New York: Springer, Fecko PJ, Simms SM, Bakirci
1981; 78. N. Fatal hypersensitivity
during
a barium
1989;
Schwartz
EE,
9.
tivity reactions 143:103-104.
896
Radiology
#{149}
Glick
GG.
SN,
during
Radiology
intubation
for small
1988; 168:39-41.
of Renal
Trauma
MD,* Morris Schoeneman, MD,t and Howard Finestone, MD* and Nephrology,t Beth Israel
Center
Avenue
and
16th
Street,
New
York,
NY 10003
Editor:
and benefited greatly from the article by Drs PolWein (1), which appeared in the August 1989 issue of Radiology, but we wish to offer an alternative view regarding the role of scintigraphy. The authors remark that “earlier proponents of scintigraphy acknowledge the dominant role now played by [computed tomography].” Their reference is to a single article, which appeared in 1985 (2). Since then, improvements in instrumentation, notably single photon emission computed tomography (SPECT) and the development of lack
and
new
radiopharmaceuticals,
toacetyltriglycine
(MAG3),
such
as technetium-99m
have
enhanced
the
mercaprole
of nuclear
imaging in detecting renal trauma (3,4). Studies comparing scmntigraphy with excretory urography have shown that Tc99m dimercaptosuccinate and Tc-99m glucoheptonate more accurately display parenchymal defects while demonstrating significant degrees of extravasation (5,6). Renal perfusion and functional compromise are better demonstrated with scintigraphy than with any other available noninvasive imaging study. Tc-99m MAG3, currently in widespread use outside the United States, provides high-resolution images even in cornpromised kidneys. Of all available imaging modalities, scmtigraphy is least dependent on patient preparation and cooperation and may be performed in the emergency department or intensive care unit. Nuclear imaging, especially if com-
bined
with
sonography,
ation as an attractive tory urography.
deserves
more
alternative
frequent
to the
more
consider-
invasive
excre-
References 1.
3.
Pollack HM, Wein AJ. Imaging of renal 172:297-308. Waxman J, Belman B, Kass EJ. Traumatic lower renal pole in children. J Urol 1985; Van Heertu.m RL, Brunetti JC, Yudd AP. ing. Semin Nucl Med 1987; 17:230-246.
trauma.
Radiology
amputation 135:114-1 Abdominal
1989;
of the left 17. SPECT
imag-
4.
Levin K, Keyes JW, Zeissman H, Haukness B. High resolution Tc 99m-DMSA SPECT renal imaging. Presented at the 36th Annual Meeting of the Society of Nuclear Medicine, St Louis, June 15, 1989.
5.
Russell
172:213-214.
5.
enema.
perforation
study.
CD,
Thorstad The
BL,
Dubovsky
EV.
triglycine,
a technetium-labeled
Strutzman
kidney:
gy 1989; 172:427-430. Barasch L. Spontaneous technetium 99m DTPA 10:107-109.
ME,
imaging
Yester
with
analog
MV,
Tc-99m
Fowler
D,
mercaptoacetyl-
of iodohippurate.
perforation of the excretory urography.
ureter Urol
Radiolo-
diagnosed on Radiol 1988;
60:404-406.
Wong
Ghahremani
Duodenal
We enjoyed
GM. Barium embolisation during a report of a case and review of the
and CT findings
MA,
Medical First
6.
Radiology
enema
a Scintigraphy
and sensitiv-
absorption
172:213.
S, Barton JR, Fraser barium enema examination: literature. BrJ Radiol 1987; FL, Tso WK,
sulfate
Barium
HM.
WC.
bowel
From: C. Richard Goldfarb, Fukiat Ongseng, MD,* Departments of Radiology*
2.
and nonfatal reactions. Systemic intravasation carries a high mortality. Younger patients have a better survival rate than older patients. It is not clear whether the barium itself or one of the many additives used is responsible for the various reaclions encountered.
References 1. Ahmed
Diner
enema
barium
an average
10.
AJR Foggs
after barium
latrogenic
MB,
enema
gastrointestinal
complireaction
153:275-276. Silverstein
examination.
GS.
Hypersensi-
AJR 1984;
of
Drs
Poliack
We their the our the
are very
and
Wein
respond:
grateful to Dr Goldfarb and his associates for enlightening comments about the role of scintigraphy in assessment of renal trauma. As we tried to emphasize in review article, there is no right or wrong way to image patient whose kidney is injured. Imaging strategies will vary with many factors, including the resources and the personal preferences of the attending physicians. We were, in fact, rather upbeat about the usefulness of radionuclide imaging of the traumatized kidney, pointing out many of its advantages. Dr Goldfarb and his colleagues further bring to the attention of the readers of Radiology the fact that new instrumentation, such as SPECT, and new radiopharmaceuticals, such
raphy
as Tc-99m
more
MAG3,
informative
may,
and
in
the
more
future,
popular.
make
If this
renal
scintig-
proves
to be
March
1990
the case, few will be displeased. Meanwhile, there are some aspects of radionuclide renal imaging-both old and newthat seem worthy of emphasis: 1. The large body of practical, day-to-day experience requmred before any modality can be accepted into routine clinical use has yet to be accumulated in the cases of SPECT and Tc-99m MAG3 imaging of the injured kidney. 2. Neither SPECT nor Tc-99m MAG3 imaging currently approaches excretory urography in availability, especially during the nonworking day. 3. The anatomical detail, especially of the renal collecting systems and ureters, depicted with excretory urography is superior to that depicted with scintigmaphic techniques.
4. The several-hour parenchymal
age the kidney acute abdominal 5. Not
delay
uptake
from
of most
injection
radiopharmaceuticals
can be a significant trauma.
everyone
would
handicap
to maximal renal used to imin the setting of
agree with the contention that “renal perfusion
of Dr and func-
Coldfarb and his co-workers tional compromise are better than with any other available
demonstrated with scintigraphy noninvasive imaging study.” Certainly, an equally strong case could be made that computed tomography, especially with bolus-administered contrast material, fits this definition just as comfortably. Once again, we thank Dr Goldfarb and his colleagues for their areas
thoughts.
We eagerly
to which
they
await
have
called
further
developments
in the
attention.
Howard M. Pollack, MD,* and Alan J. Wein, MD1 Departments of Radiology* and Surgery,t University Pennsylvania School of Medicine and Hospital 3400 Spruce Street, Philadelphia, PA 19104
of
dilional contrast media are studied, such use may lead to confusion. The drug used in each of the studies cited was gadopentetate dimeglumine, which is the United States Adopted Name (USAN)
for the trademarked
known
Use
From:
Harold
Berlex
Laboratories,
300 Fairfield
of Names
A. Goldstein, Inc Road, Wayne,
for
MR
Contrast
As other
MR contrast
Recently,
several
in which “Cd-DTPA”
the terms
NJ 07470
Volume
174
are described (nonproprietary), (1-7)
articles used
Number
#{149}
containing
different
safety
and
efficacy
active
sub-
names will their various
characteristics.
References 1. Carvlin MJ, Arger PH, Kundel HL, et al. Use of Gd-DTPA and fast gradient-echo and spin-echo MR imaging to demonstrate renal function in the rabbit. Radiology 1989; 170:705-711. 2. Choyke PL, Frank JA, Girton ME, et al. Dynamic Gd-DTPA-enhanced MR imaging of the kidney: experimental results. Radiology 1989; 170:713-720. 3. Elster AD, Moody DM, Bail MR, Laster DW. Is Gd-DTPA required for routine cranial MR imaging? Radiology 1989; 173:231-238. 4. Erlemann R, Reiser MF, Peters PE, et al. Musculoskeletal neoplasms: static and dynamic Gd-DTPA-enhanced MR imaging. Radiology 1989; 171:767-773. 5. Heywang SH, Wolf A, Pruss E, Hilbertz T, Eiermann W, Permanetter W. MR imaging of the breast with Gd-DTPA: use and limitations. Radiology 1989; 171:95-103. 6. Krestin GP, Steinbrich W, Fnedmann G. Adrenal masses: evaluation with fast gradient-echo MR imaging and Gd-DTPA-enhanced dynamic studies. Radiology 1989; 171:675-680. 7.
Yoshida
H, Itai Y, Ohtomo
hepatocellular
Radiology
with
K, Kokubo
carcinoma dynamic
1, Minami
and cavernous
FLASH
MR imaging
(RSNA
‘89 annual
M, Yashiro
hemangioma: with
N.
dif-
Gd-DTPA.
1989; 171:339-342.
Erratum
have
by several specific and brand name appeared
in Radiology,
“gadolinium,” “gadolinium DTPA,” and for the magnetic resonance (MR) imaging contrast medium gadopentetate dimeglumine. While at one lime use of these terms may have been acceptable, as adwere
media
stances are developed, the use of the appropriate be necessary to differentiate the products with
MD
Editor: What’s in a name? Drugs names: chemical, generic or trademark (proprietary).
chemically
dihydrogen
gadolinate (2-) (2:1). This substance is the first and only paramagnetic MR contrast medium commercially available for routine clinical use in the United States.
ferentiation
Appropriate Media
injection,
[N,N-bis[2-[bis(carboxymethyl)aminojethyl]glycinato-(5-)]-
Small
.
Magnevist
as 1-deoxy-1-(methylammno)-D-glucitol
3
Radiology
1989;
173(P):434
program)
Paper 1405, “Use of In-il 1-labeled Nonspecific Polyclonal IgG in Patients with Acute Inflammation or Infectious Processes,” should be amended to include the following authors: Paulo A. Carvalho, MD, Annikke D. Van Den Abbeele, MD, James Maguire, MD, Rebecca A. Aaronson, MA, Amin I. Kassis, PhD, William C. DeSisto, CNMT, Sabah S. Tumeh, MD.
Radiology
#{149} 897
