1. Conservative treatment Barium extravasation of rectum- a case report
湯堯舜 黃宏昌
魏柏立 郭立人

2. Patient profile 沈XX 04114291 Sex: female Age: 55-year-old
Admission on 06/30/2016
Source of patient: ER
Nativity : Taiwan
Occupation : 會計
Marital status : divorce
Body weight 70Kg
Body height 160cm
BMI: kg / m2

3. Chief complaint
Abdominal pain with fever after barium enema study

4. Present illness Type II DM / Hypertension
s/p laparoscopic cholecystectomy in CGMH
Watery diarrhea alt with constipation in recent half year
Abdominal cramping before defecation, relieved after defecation
6/14 colonoscopy: incomplete-- Colonic spasm, acute angulation –no invasive procedure performed
Arrange barium enema on 6/30

5. Barium enema 08:30 am
The examination was stopped because the patient complained persisnent lower abdominal discomfort during barium enema

6. ER 20:00 6/30 Vital sign: 37.3 degree, 82bpm, 16/min
149/85mmHg 100%, GCS: E4V5M6
PE: abdominal soft
No muscle guarding

7. 6/30

8. Impression
1.Iatrogenic retroperitoneal rectal perforation 2.Diabetes mellitus Type II 3.Hypertension

9. Treatment NPO, hydration Flumarin 1000mg q8h
PPN with Aminofluid 1000ml/day

10. One week
Flumarin 1000mg/Q8H
WBC
7700
6330
Neu %
72.1 61
CRP
5.59
0.75

11. Flumarin 1000mg/Q8H + SABS 500mg
One week
Flumarin 1000mg/Q8H + SABS 500mg
WBC
8280
5720
Neu %
73.4
63.3
CRP
1.45
2.26
Procalcitonin (PCT) [前降鈣素原檢查] ng/ml [<0.046

12. WBC
5720
4280
Neu %
63.3
53.5
CRP
2.26
0.63

13. WBC
2.86
Neu %
54.9
CRP
0.5

14. 7/07

15. 9/30

16. Current complaint
Perianal pain when stool passage

17. colon rectal injury after DCBS
Incidence : %
The most common: (high insertion of the rigid catheter and excessive inflation of the catheter balloon), ---- the perforation of the more vulnerable anterior part of the rectum.
The second mechanism is perforation due to a weakened colonic mucosa (secondary to obstruction, diverticulitis, ischemic colitis, recent biopsies or old age)

18. In this case Need operation ? The timing of operation NPO period
Delay complication

19. Classification
1.Perforations of the anal canal below the levator ani muscle
2. Incomplete perforations such as perforation of the rectal mucosa
3. Perforations into the retroperitoneum
4. Transmural perforations into the adjacent viscera
5. Perforations into the free intraperitoneal cavity.
Peterson N, Rohrmann CA Jr, Lennard ES. Diagnosis and treatment of retroperitoneal perforation complicating the double-contrast barium-enema examination. Radiology 1982;144:

20. Free perforation into peritonium: mortality rate 35~50%
Pathophysiology
1hr migration of polymorphonuclear cells
3hrs mononuclear cells appear
6hrs –3~5 days Fibrinous adhesions appear --leads to firm adhesions
One month later, the barium particles are completely encapsulated by the surrounding tissues, and adhesions are firm and massive.
After five months: Giant cells surround the encapsulated barium particles
Free perforation into peritonium: mortality rate 35~50%

21. Review
Dis Colon Rectum 2005; 49: 261–271

22. Treatment Intraperitoneal perforation: open lavage
Fresh infralevator perforations with large mucosal lesions or anal sphincter lesions must be repaired
Retroperitoneal perforation: conservative treatment
---Diverting colostomy + drainage(if toxic sign developed)
Perirectal abscesses (ischiorectal/precoccygeal) require drainage.
Rectosigmoid resection / primary anastomosis, and proximal colostomy

23. Late complication Stricture Chronic abscess formation
--fistula formation
Retroperitoneal fibrosis
--paralytic ileus
--ureteral obstruction-hydronephrosis

24. Thanks for your attention