Gastrointest Radiol 15 :76-77 (1990)
Gastrointestinal
Radiology 9 Springer-VerlagNewYorkInc. 1990
Spontaneous Dissection of Air into the Transverse Mesocolon during Double-Contrast Barium Enema Kyunghee C. Cho, 1 Marc Z. Simmons, 1 Stephen R. Baker, 1 and Mitchell S. Cappell 2 Department of 1 Radiology and z Division of Gastroenterology of the Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
Abstract. Intramural perforation of the colon proximal to the rectosigmoid is a rare complication of the barium enema examination. We present a case in which air and barium entered the wall of the transverse colon, and then dissected through the transverse mesocolon during double-contrast barium enema in an asymptomatic patient with no known underlying colonic disease.
Key words: Pneumatosis coli, diagnosis enema, complications.
Barium
A 51-year-old female underwent a double-contrast barium enema examination for the evaluation of anemia. There was no history of fever, abdominal pain, diarrhea, or gastrointestinal bleeding. The study was performed using a nondistended rectal tube. The patient did not experience pain during the procedure. At fluoroscopy, there was no evidence of extraluminal penetration of gas or barium. However, upon review of the overhead films, a linear collection of intramural gas was noted along both the inferior and superior walls of the transverse colon, and there was also a large area of streaky and irregular lucencies in the epigastrium that were not noted on the scout film (Fig. 1 A and B). A barium enema also revealed numerous diverticula in the right colon, and a few outpouchings in the appendix and the terminal ileum. There were no ulcers or masses in the colon. A supine film of the abdomen 24 h later showed streaks of intramural barium paralleling the entire length of the transverse colon (Fig. 1 C). Computed Kyunghee C. Cho, M.D., Department of Radiology, BMHC, Albert Einstein College of Medicine, Bronx, NY 10461, USA Address reprint requests to:
tomography (CT) of the abdomen performed five days after the barium enema confirmed the presence of residual air in the transverse mesocolon. The patient remained free of pain and never developed fever or leukocytosis. Discussion
Dissection of gas and contrast material into the colonic wall is an unusual complication of the barium enema examination [1-6]. It occurs most frequently in the rectum, and is generally associated with such predisposing conditions as anal fissure, mucosal inflammation, or malignancy [1, 2]. Another factor is trauma to the mucosa abraded or perforated by a catheter tip, an inflated rectal balloon, or scybalous feces. Intramural penetration by barium is usually a self-limited complication. However, dissection of the colonic wall by barium may interrupt the vascular supply to the bowel with secondary gangrene [3]. Rarely, massive intravasation of barium suspension may occur, resulting in immediate death [4]. Intramural perforation of the more proximal large bowel is less common. Penetration of barium into the sigmoid wall has been reported with an obstructing carcinoma [3]. Ulcerative colitis was the cause in another case involving the transverse colon [5]. Intramural penetration of the cecum has been noted in a patient with no known underlying colonic disease. A postulated cause was elevated intraluminal pressure in the cecum, which resulted in disruption of the mucosa, allowing gas to enter the wall [6]. In our case involving a seemingly normal transverse colon, the patient remained completely asymptomatic during and after the barium enema examination. Although the site of perforation was not demonstrated, we speculate that cecal disten-
K.C. Cho et al. : Spontaneous Dissection of Air into the Mesocolon
77
Fig. 1. A Double-contrast barium enema. B Postevacuation film. Intramural air is seen paralleling the margins of the transverse colon (arrowheads). The irregular streaky lucencies above the transverse colon represent air dissected into the transverse mesocolon (open arrows). Note numerous diverticula in the ascending colon (A C). C Supine film 24 h after the barium enema, showing curvilinear intramural barium collection outlining the entire course of the transverse colon (arrowheads).
sion was restricted by massed diverticulosis of the right colon, placing the transverse colonic wall at risk for injury by the pressure of abrupt dilatation during the examination. Air then entered the bowel wall and later dissected into the leaves of the transverse mesocolon. Barium was not seen at first and presumably entered the wall after colonic contraction, forcing the contrast material through the mucosal rent created during the barium enema. References 1. Carter R W : Barium granuloma of the rectum, a complication of diagnostic barium enema examinations. A JR 89: 880-882, 1963
2. Carney JA, Stephens D H : Intramural barium (barium granuloma) of the colon and rectum. Gastroenterol 65:316-320, 1973 3. Spector GW, Susman N: The roentgen recognition of intramural perforation following barium enema examination in obstructing lesions of the sigmoid. A JR 89."876-879, 1963 4. Cove JKJ, Snyder R N : Fatal barium intravasation during barium enema. Radiology 112: 9-10, 1974 5. Desaulniers M: Intramural penetration of barium - transverse colon. J Can Assoc Radiol 29:194, 1978 6. Seaman WB, Bragg D G : Colonic intramural barium: a complication of the barium enema examination. Radiology 89.'250-255, 1967
Received: April 24, 1989; accepted. June 6, 1989
Gastrointestinal
Radiology 9 Springer-VerlagNewYorkInc. 1990
Spontaneous Dissection of Air into the Transverse Mesocolon during Double-Contrast Barium Enema Kyunghee C. Cho, 1 Marc Z. Simmons, 1 Stephen R. Baker, 1 and Mitchell S. Cappell 2 Department of 1 Radiology and z Division of Gastroenterology of the Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
Abstract. Intramural perforation of the colon proximal to the rectosigmoid is a rare complication of the barium enema examination. We present a case in which air and barium entered the wall of the transverse colon, and then dissected through the transverse mesocolon during double-contrast barium enema in an asymptomatic patient with no known underlying colonic disease.
Key words: Pneumatosis coli, diagnosis enema, complications.
Barium
A 51-year-old female underwent a double-contrast barium enema examination for the evaluation of anemia. There was no history of fever, abdominal pain, diarrhea, or gastrointestinal bleeding. The study was performed using a nondistended rectal tube. The patient did not experience pain during the procedure. At fluoroscopy, there was no evidence of extraluminal penetration of gas or barium. However, upon review of the overhead films, a linear collection of intramural gas was noted along both the inferior and superior walls of the transverse colon, and there was also a large area of streaky and irregular lucencies in the epigastrium that were not noted on the scout film (Fig. 1 A and B). A barium enema also revealed numerous diverticula in the right colon, and a few outpouchings in the appendix and the terminal ileum. There were no ulcers or masses in the colon. A supine film of the abdomen 24 h later showed streaks of intramural barium paralleling the entire length of the transverse colon (Fig. 1 C). Computed Kyunghee C. Cho, M.D., Department of Radiology, BMHC, Albert Einstein College of Medicine, Bronx, NY 10461, USA Address reprint requests to:
tomography (CT) of the abdomen performed five days after the barium enema confirmed the presence of residual air in the transverse mesocolon. The patient remained free of pain and never developed fever or leukocytosis. Discussion
Dissection of gas and contrast material into the colonic wall is an unusual complication of the barium enema examination [1-6]. It occurs most frequently in the rectum, and is generally associated with such predisposing conditions as anal fissure, mucosal inflammation, or malignancy [1, 2]. Another factor is trauma to the mucosa abraded or perforated by a catheter tip, an inflated rectal balloon, or scybalous feces. Intramural penetration by barium is usually a self-limited complication. However, dissection of the colonic wall by barium may interrupt the vascular supply to the bowel with secondary gangrene [3]. Rarely, massive intravasation of barium suspension may occur, resulting in immediate death [4]. Intramural perforation of the more proximal large bowel is less common. Penetration of barium into the sigmoid wall has been reported with an obstructing carcinoma [3]. Ulcerative colitis was the cause in another case involving the transverse colon [5]. Intramural penetration of the cecum has been noted in a patient with no known underlying colonic disease. A postulated cause was elevated intraluminal pressure in the cecum, which resulted in disruption of the mucosa, allowing gas to enter the wall [6]. In our case involving a seemingly normal transverse colon, the patient remained completely asymptomatic during and after the barium enema examination. Although the site of perforation was not demonstrated, we speculate that cecal disten-
K.C. Cho et al. : Spontaneous Dissection of Air into the Mesocolon
77
Fig. 1. A Double-contrast barium enema. B Postevacuation film. Intramural air is seen paralleling the margins of the transverse colon (arrowheads). The irregular streaky lucencies above the transverse colon represent air dissected into the transverse mesocolon (open arrows). Note numerous diverticula in the ascending colon (A C). C Supine film 24 h after the barium enema, showing curvilinear intramural barium collection outlining the entire course of the transverse colon (arrowheads).
sion was restricted by massed diverticulosis of the right colon, placing the transverse colonic wall at risk for injury by the pressure of abrupt dilatation during the examination. Air then entered the bowel wall and later dissected into the leaves of the transverse mesocolon. Barium was not seen at first and presumably entered the wall after colonic contraction, forcing the contrast material through the mucosal rent created during the barium enema. References 1. Carter R W : Barium granuloma of the rectum, a complication of diagnostic barium enema examinations. A JR 89: 880-882, 1963
2. Carney JA, Stephens D H : Intramural barium (barium granuloma) of the colon and rectum. Gastroenterol 65:316-320, 1973 3. Spector GW, Susman N: The roentgen recognition of intramural perforation following barium enema examination in obstructing lesions of the sigmoid. A JR 89."876-879, 1963 4. Cove JKJ, Snyder R N : Fatal barium intravasation during barium enema. Radiology 112: 9-10, 1974 5. Desaulniers M: Intramural penetration of barium - transverse colon. J Can Assoc Radiol 29:194, 1978 6. Seaman WB, Bragg D G : Colonic intramural barium: a complication of the barium enema examination. Radiology 89.'250-255, 1967
Received: April 24, 1989; accepted. June 6, 1989
