ROBERT H. WESTFALL, M.D., ROBERT H. NELSON, AND MERLE M. MUSSELMAN, M.D., Omaha, Nebraska
From the Department of Surgery, University College of Medicine, Omaha, Nebraska.
HE ACCIDENTAL introduction of barium sulsuspension into the peritoneal cavity produces acute peritonitis. The severity of the peritonitis is proportional to the quantity of barium introduced into the peritoneal cavity. Barium peritonitis is associated with a high mortality and an increased hazard of future bowel obstruction in the survivors. Rosenthal [I ] reported the first case of barium peritonitis in 1916. Since that time the literature shows scattered reports of barium peritonitis, but it seems likely that this event occurs more frequently. In 1952 Zheutlin, Lasser, and Rigler  questioned 100 teaching institutions regarding barium spillage into the peritoneal cavity in patients through perforation of the colon. They collected fifty-three cases from thirty-five institutions and found a mortality of 51 per cent. In the past year we treated two patients with barium peritonitis at the University of Nebraska Hospital. Both patients survived but one suffers from recurrent episodes of small bowel obstruction. This experience stimulated us to undertake an experimental study of barium peritonitis. Our objectives were to study the removal of barium from the peritoneal cavity and to determine if the efficient removal of barium reduced subsequent adhesion formation.
RESULTS In the animals treated by operation, preoperative roentgenograms demonstrated the spread of barium throughout the peritoneal cavity. (Fig. 1.) This spread occurred even though the barium had been injected into the left lower quadrant and the animals remained anesthetized and on their backs. At operation the volume of free peritoneal fluid exceeded the volume of barium suspension
MATERIAL AND METHODS We used a sterile 1:4 suspension of a commercial
barium sulfate preparation used by our Department of Radiology for barium enema examinations, injecting 5 ml. of this suspension per kilogram of body * Presented at the Eighteenth
weight into the left lower quadrant of mongrel dogs. This quantity of barium is approximately one fourth of the amount used in a barium enema examination, Four dogs were used as controls. After the injection of barium the control animals were returned to their cages to await examination for adhesions in eight weeks. In the remaining animals celiotomy was performed under sterile conditions two hours after the injection of barium into the peritoneal cavity. We attempted to remove the barium from the peritoneal cavity by one of the following methods: (1) irrigation of the peritoneal cavity with normal saline solution at 1 L./IO kg.; (2) irrigation with a solution containing one part hydrogen peroxide to four parts normal saline solution at 1 L./IO kg.; (3) irrigation with normal saline solution as 1 L./IO kg. combined with removal of the greater omentum; (4) irrigation with the saline-hydrogen peroxide solution at 1 L./l0 kg. combined with removal of the greater omentum. We assessed the removal of barium from the peritoneal cavity by gross observation, photographs taken at operation, and x-rays taken before and after operation. Biopsy specimens were taken from various tissues where barium had accumulated and peritoneal fluid from some of the animals was sent to the laboratory for chemical analysis. All surviving animals were operated upon eight weeks after the injection of barium to evaluate the formation of adhesions.
Annual Meeting of the Southwestern April 18-21, 1966. 760
Surgical Congress, Las Vegas, Nevada,
injected into the peritoneal cavity. =Inalysis of this fluid showed an electrolyte and protein content similar to extracellular fluid and is as follows : osmolarity, 290 mOsm/L. ; sodium, 138 nig. per cent; potassium, 4.1 mg. per cent; and total serum protein, 4 mg. per cent (albumin 2.9 gm. per cent, globulin 1.1 per cent). The peritoneal fluid contained barium which settled to the bottom of the container after aspiration from the abdominal cavity. Exploration of the peritoneal cavity two hours after the injection of barium revealed that some of the barium remained in suspension. However, much of the barium settled out on the omentum, in the lateral peritoneal gutters, and diffusely in granular particles over the abdominal organs. (Fig. 2.) Handling of the bowel gave a sandy, grating sensation, There were small hemorrhagic areas in the mesentery of the small bowel which increased with manipulation of the intestines. (Fig. 3.) Minimal and gentle handling of the intestines avoided this abrasive irritation. Irrigation of the peritoneal cavity removed barium particles that remained in suspension or free on the visceral surfaces. However, after irrigation barium persisted in many areas. A large quantity of barium always remained in the omentum, which could not be removed by direct irrigation or wiping with a gauze sponge. Smaller clumps of barium remained in the lateral gutters and mesentery of the small bowel. These clumps of barium were equally
FIG. 1. I’rcopcrativ~ radiograph taken two hours after the injc.ction of barium into the peritoncnl cavity. Barium spread tin-cxlxhout the abdominal cavit?
adherent and biopsy of these areas showed leukocytic infiltration and a thin fibrin menbrane covering the surface of the barium. (Fig. -1.) The quantity of barium removed by irrigation lvith normal saline solution appeared equal to that removed by the saline-hydrogen peroxide solution. The greater omentum contained the largest quantity of barium that remained after irrigation. Irrigation with removal of the
FIG. 2. Operative photograph two hours after the injection and in a segment of the mesentery of the small bowel.
of barium shows the collection
FIG. 3. Operative
areas in mesentery
of small bowel.
FIG. 4. Photomicrograph from biopsy of omentai barium two hours after intraperitoneal is marked leukocytic infiltration with a thin fibrin membrane covering the surface. Vol. 112, November
of barium in the omcntum
and Musselman adhesions, most of which extended between the omentum and the adjacent bowel mesentery. In the control animals and those animals who had excessive operative manipulation early in the study multiple adhesions developed. (Fig. 6.) Fewer adhesions developed in the animals treated by irrigation. There was no apparent difference in adhesion formation between those animals whose peritoneal cavities were irrigated with normal saline solution and those whose peritoneal cavities were irrigated with the saline-hydrogen peroxide solution. The least adhesions formed in those animals treated by irrigation of the peritoneal cavity and removal of the greater omentum. (Fig. 7.)
FIG. 5. Postoperative roentgenograms after the attempted removal of barium indicated that (A) irrigation of the peritoneal cavity plus removal of the greater omentum removed a larger quantity of barium than (B) irrigation alone.
greater omentum appeared to remove the largest quantity of barium from the peritoneal cavity. Comparison of postoperative roentgenograms substantiated this impression. (Fig. 5.) At the second operation eight weeks later all animals had residual barium in the peritoneal cavity. This barium generally appeared as scattered isolated clumps 3 to 5 mm. in diameter, the surfaces of which were covered by thin transparent membranes. All animals had
FIG. 6. Operative photograph adhesions.
FIG. 7. Operative photograph the greater omentum.
When a sufficient quantity of barium sulfate suspension enters the peritoneal cavity, the patient notes localized abdominal pain which soon becomes generalized. This clinical finding correlates with the radiographic observation that barium spreads rapidly into all areas of the peritoneal cavity. The patient may show tachycardia and hypotension which is likely secondary to an outpouring of extracellular fluid into the peritoneal cavity producing hypovolemia. We found an increased volume of free peritoneal fluid after the injection of barium. On analysis, this fluid was similar to extracellular fluid in electrolyte and protein content. We believe that this outpouring of extracellular
from control animal taken eight weeks after injection of barium demonstrates demonstrates
adhesive band formed in animal treated by irrigation and removal of
Barium fluid is secondary to the mechanical irritation of the abdominal viscera by the granular particles in the barium suspension. Thomas ant1 others [Z-P] studied the histologic changes that occur in barium peritonitis. They found that within sixty minutes after the injection of barium into the peritoneal cavity, the barium accumulated into small clumps covered by a thin film of fibrin. We found that these clumps \vere adherent and could not be removed by irrigation or mechanical wiping. However, tw-o hours after injection of barium in the peritoneal cavity we discovered that considerable barium remained in suspension and could be removed easily by irrigation. Almond, Cochran, and Shucart  found that a sterile commercial barium sulfate suspension was as noxious as feces in the peritoneal cavity and produced more adhesions. They observed that the combination of feces and sterile barium suspension injected into the peritoneal cavity of dogs was invariably fatal. When barium enters the peritoneal cavity through a perforation of the colon during barium examination, associated fecal contamination is certain. The literature on barium peritonitis indicates that barium in the peritoneal cavity produces adhesions and the increased hazard of bowel obstruction. In their collected cases Zheutlin, Lasser, and Rigler  noted that 30 per cent of the patients suffered from recurrent bouts of small bowel obstruction. In our study adhesions were found to develop in all animals. We observed that the fewest adhesions occurred in those animals treated by gentle operative manipulation, irrigation of the peritoneal cav-
Vol. 112, November
Peritonitis ity with normal saline solution, the greater omentum.
Barium sulfate suspension in the peritoneal cavity produces severe peritonitis with a high mortality. The logical treatment of barium peritonitis is antibiotics for possible fecal contamination, parenteral fluids for hypovolemia, and early operation to treat the perforation and remove the barium sulfate. Copious irrigation of the peritoneal cavity with normal saline solution combined with removal of the greater omentum removes the largest quantity of baradherent clumps of barium ium. Scattered should be disregarded. Attempting to remove these clumps is unsuccessful and the added operative manipulation enhances chances for subsequent formation of adhesions. REFERENCES 1. ROSENTHAL,E. Rontgenologisch
beobachlete Magenperforation. Berl. klin. Wchnschr., 53: 945, 1916. Cited by de Fonseka, C. P. Acute perforation of a duodenal ulcer immediately after barium meal complicated by intestinal obstruction. Lancer, 263: 1246, 1952. ZHEUTLIN, N., LASSER, E. C., and RIGLER. L. G. Clinical studies on effect of barium in the peritoneal cavity following rupture of the colon. Surgery, 32: 967, 1952. THOMAS, J. C. The disposal of barium sulfate in the abdominal cavity. J. Path. & Bacl., 43: 285, 1936. KAY, S. and CHOW, S. H. Results of intraperitoneal injection of barium sulfate contrast medium. Arch. Path., 59: 388, 1955. ALMOND, C. H., COCHRAN, D. Q., and SHUCART, W. A. Comparative study effects of various radiographic contrast media on the peritoneal cavity. Ann. Surg., 154: 219 (Suppl.), 1961.