Gastrointestinal

Gastrointest Radiol 16:2%31 (~991)

Radiology 9 Springer-VerlagNewYorklnc.1991

Small Bowel Perforation During Enteroclysis Sergio Ginaldi Department of Radiology, Tallahassee Memorial Regional Medical Center, Tallahassee, Florida, USA

Abstract. Small bowel perforation with massive intraperitoneal leakage of barium occurred during the performance of enteroclysis in a 72-year-old woman. It is postulated that an ischemic segment of the partially obstructed ileum had ruptured because of rapid intraluminal flow of contrast material and increased abdominal pressure when the patient was rotated to a prone position. Key words: Intestine, p e r f o r a t i o n - Enteroclysis, complications.

Intestinal obstruction is a common clinical problem, and radiologists are often confronted with a diagnostic challenge in delineating the precise site and nature of the obstructive lesion. Enteroclysis is being used with an increasing frequency in evaluating patients with small bowel obstruction [1-9]. The procedure is described to be virtually free of complications or specific contraindications [9, 10]. In the herein reported case, however, small bowel perforation during enteroclysis was documented on serial radiographs and confirmed at surgery. Case Report A 72-year-old woman presented with a history of abdominal cramping, nausea, and then vomiting for 18-24 h prior to the admission. The previous clinical history was remarkable for numerous medical problems, including cardiac angina, diabetes mellitus, and ischemic colitis, as well as multiple surgical procedures including cholecystectomy, appendectomy, coronary arAddress offprint requests to: Sergio Ginaldi, M.D., Department of Radiology, Tallahassee Memorial Regional Medical Center, Magnolia Drive and Miccosukee Road, Tallahassee, FL 32303, USA

tery bypass, and aortofemoral bypass. She was a heavy smoker. The patient was on numerous cardiac and antihypertensive drugs, as well as on insulin. Examination showed a distended abdomen without rebounding or masses present. She was afebrile. No blood was present on rectal examination. Abdominal radiographs showed minimally dilated loops of small bowel with air-fluid levels visible in an upright position. The findings, in light of the clinical history, were felt to be compatible with early or partial small bowel obstruction. A nasogastric tube was inserted with gradual relief of abdominal distension, but she continued to experience some emesis. A computed tomographic scan of the abdomen, performed on the third hospital day, demonstrated the proximal two thirds of the small bowel to be dilated without apparent cause. No localized masses, thickened bowel wall, or free abdominal fluid were apparent. To achieve a definite diagnosis, an enteroclysis was performed on the fourth hospital day. Intubation was done with a 13French Maglinte catheter, which was positioned with its tip at the level of the proximal jejunum; the balloon was inflated with 20 ml room air. The intubation was performed without difficulty or use of medicaments. Approximately 180 ml of Entrobar was then injected by hand at the rate of approximately 80 ml/min under fluoroscopic control and gradual external compression. The visualized small bowel loops demonstrated obvious kinking, probably from underlying adhesions, but free flow was demonstrated to the level of the mid-pelvic ileum. No intraluminaI abnormalities were seen on compression radiography. At this time, the first 70 ml of methylcellulose was injected and, to promote a better progression of contrast, the patient was rotated from the supine to .the prone position. The patient experienced acute abdominal pain and, under fluoroscopy, a large amount of contrast extravasation into the peritoneal cavity became obvious (Fig. 1 A and B). Immediate surgical consultation was obtained and laparotomy disclosed a focal area of perforation in the mid-ileum at about 13 cm from the most distal loop of bowel visualized by contrast during enteroclysis. No foreign bodies, ulcerations, or discoloration of bowel were present in the region of the perforation, although proximally the bowel appeared edematous. Repair of the site of perforation did not require bowel resection but limited local suturing. About 13 cm from the site of the perforation, a constricting band was noted. Distal to this point, the bowel was of normal caliber and free of masses. Extensive lysis of adhesions was performed. The postoperative course was complicated by several episodes of hypotension, renal failure, and cardiac decompensation. The patient died 3 days later.

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Fig. l . A Initial radiograph showing the enteroclysis tube with its inflated balloon in the proximal jejunum. The opacified bowel loops are dilated due to an apparent obstruction in the mid-ileum (arrows). B Subsequent radiograph demonstrates perforation of distal small bowel, causing massive intraperitoneal leakage of barium. Note the unchanged position of the enteroclysis tube proximal to the ruptured segment.

Discussion

Enteroclysis has been advocated in both radiological and surgical literature as the study of choice for evaluation of clinically questionable small bowel obstruction [5-8]. No complications directly attributed to this technique have been reported [9-10[. The only negative experience described in the literature has been a case of duodenal perforation caused by malposition of the enteroclysis tube [11]. The cause of perforation in our patient is speculative and its triggering mechanisms are probably numerous. Rupture occurred at a significant distance from the tip of the nasojejunal tube and proximal to the site of a more complete adhesive

S. Ginaldi : Small Bowel Perforation During Enteroclysis

obstruction. No volvulus was apparent under fluoroscopy and the bowel lumen was clearly wider than the balloon. Acute increases in intraabdominal pressure, such as during straining, Valsalva maneuver, or by external pressure, can decrease intestinal blood flow. A mechanism of sudden external compression was certainly present at the time the patient was turned to the prone position; it could have caused an immediate fall in intestinal blood flow, particularly in areas with possibly intravascular coagulation complicating a low cardiac output state [/2]. Indeed, the edematous bowel wall observed at surgery proximal to the area of perforation could have been due to ischemic damage. Whether the precarious clinical conditions of the patient may have influenced the outcome of the study is only a speculation, despite a strong relationship between cardiovascular disease, diabetes, and bowel ischemia [12]. It is reasonable to assume that a combination of different factors, including the degree of intestinal distension and intraluminal pressure during enteroclysis, as well as the decreased blood flow to the partially obstructed small

S. Ginaldi: Small Bowel Perforation During Enteroclysis

bowel acted as triggering mechanisms, which led to the perforation. We have performed enteroclysis for suspected adhesive obstruction in many patients without complications. We now limit the fluoroscopic and radiographic evaluation to supine and oblique positions, thus avoiding placement of the patient into the prone position. If significant obstruction is identified on plain radiographs, we perform enteroclysis only after introduction of a deflating tube. Patients with histories of severe atherosclerosis, ischemic bowel disease, and long-standing diabetes are now informed about this potential complication. References 1, Sellink JL: Examination of the Small Bowel Intestine by Means of Duodenal Intubation. Leiden: Stefert Kroese, 1971 2, Maglinte DDT, Burney BT, Miller RE: Lesions missed on small bowel follow-through: Analysis and recommendations. Radiology 144: 737-739, 1982 3, Gurian L, Jendrzehewski J, Katon R, et al. : Small bowel enema: An underutilized method of small bowel examination. Dig Dis Sci 27:1101-1108, 1982

31 4. Diner WC, Hoskins EOL, Navab F: Radiologic examination of the small intestine: Review of 402 cases and discussion of indications and methods. South Med J 77:68-74, 1984 5. Maglinte DDT, Miller RE: Intubation infusion method: Reliability in diagnosis of mechanical partial small bowel obstruction. Mt Sinai J Med 51:372-377, 1984 6. Maglinte DDT, Peterson LA, Vahey TN, et al. : Enteroclysis in partial small bowel obstruction. Am J Surg 147:325 329, 1984 7. Roediger WEW, Marshall VC, Roberts S: Value of small bowel enema in incomplete intestinal obstruction. Aust N Z J Surg 52: 507-509, 1982 8. Caroline DF, Herlinger H, Laufer I, et al. : Small bowel enema in the diagnosis of adhesive obstructions. A JR 142:1133-1139, 1984 9. Maglinte DDT, Lappas JC, Kelvin FM, Rex D, Chernish SM: Small bowel radiography: How, when, and why? Radiology 163 :297-305, 1987 10. Maglinte DDT: Balloon enteroclysis catheter. A JR 143:761-762, 1984 11. Diner W: Duodenal perforation during intubation for small bowel enema study. Radiology 168: 39~41, 1988 12. Boley SJ, Agrawal GP, Warren AR, Veith FJ, Levowitz BS, Treiber W, Dougherty J, Schwartz SS, Gliedman ML: Pathophysiologic effects of bowel distension on intestinal blood flow. Am J Surg 228-234, 1969 Received: February 26, 1990," accepted: March 27, 1990

Small bowel perforation during enteroclysis.

Small bowel perforation with massive intraperitoneal leakage of barium occurred during the performance of enteroclysis in a 72-year-old woman. It is p...
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