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Barium Impaction Ileus in a Child Using the PIE*Procedure
Letter to the Editor, Journal of Pediatric Gastroenterology and Nutrition, 21:119-120, 1995
Mark A Gilger, M.D., Milton L. Wagner, Gloria T. Kelley, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas U.S.A
To the Editor:
Barium contrast examinations, utilizing either barium meal
or enema, are still a common choice for visualization of the
gastrointestinal tract in children. After completion of these
x-ray procedures, the contrast material should be thoroughly
evacuated from the bowel. Residual barium sulfate remaining
in the gastrointestinal tract has the potential to harden,
forming true "concretions" that can become impacted.
Purgatives or enemas are often given after barium studies to
ensure complete evacuation of the contrast material. However,
once a barium impaction has formed in the colon, routine enema
preparations such as phosphosoda, oil retention, tap water,
and soap suds are frequently ineffective. Recently, the pulsed
irrigation for enhanced evacuation (PIEE) (Avatar 2000 Bowel
Evacuation System, Aegis Medical, Denver, CO, U.S.A.) procedure
was introduced as a simple, effective method for removal of
rectal impaction in adults and children (1,2). PIEE is an automated
enema in which small pulses of warm tap water are delivered
into the rectum, serving to rehydrate feces and promote peristalsis.
We report the successful evacuation of a severe barium impaction
in a child with total colonic Hirschsprung's disease using
the PIEE procedure.
A 4-year old hispanic boy with total colonic Hirschsprung's
disease and severe constipation presented to Texas Children's
Hospital with a 2-day history of marked abdominal distension
and obstipation. A barium enema had been performed at another
hospital 2 days prior. After the barium enema, the patient
had no spontaneous bowel movements. The patient's mother
performed four 250 ml saline and three 250 ml tap water enemas
at home with minimal evacuation of the contrast material.
On presentation to Texas Children's Hospital, the child
was alert and cooperative. His vital signs were: temperature,
37.4°C; pulse, 88; respiratory rate, 20; blood pressure,
100/60; and weight, 36.4 kg. Abdominal examination revealed
marked distension, normal bowel sounds, no hepatosplenomegaly,
and mild tenderness in the left lower quadrant with a firm
but mobile palpable mass. Rectal examination revealed firm,
guaiac-negative clay-colored feces in a markedly dilated
rectal vault. A supine radiograph revealed a markedly dilated
colon filled with barium. Complete blood count and electrolyte
levels were normal.
Since seven routine enemas had been unsuccessful in relieving
the barium impaction and since the mother refused to return
to the radiology suite for a gastrografin enema, a PIEE procedure
was performed. After one PIEE cycle, the patient had minimal
fecal output and the left lower quadrant fecal mass remained
palpable. After the patient rested for 30 min to allow electrolyte
equilibration, a second PIEE cycle was performed. The patient
then had a large clay-colored fecal output. A repeat supine
radiograph revealed nearly complete passage of contrast material
but continued colonic distension.
Barium sulfate impaction of the colon is uncommon in children.
When encountered, there are usually predisposing conditions,
such as intestinal dysmotility, postoperative ileus, or,
as in our case, Hirschsprung's disease. The PIEE procedure
is a new method to remove fecal impactions that requires
no radiation exposure or manual disimpaction (1). We have
previously demonstrated PIEE to be effective and safe in
evacuating fecal impactions in normal children (1). In this
child with profound colonic inertia, PIEE proved successful
in removing a right-sided barium impaction after multiple
routine enemas had failed. The ability of the PIEE procedure
to treat this type of impaction makes it an equally effective
alternative to gastrografin (3-9) enemas, with no radiation
exposure. In summary, we report the successful evacuation
of a barium impaction of the colon using the PIEE procedure.
We emphasize its use in patients with significant colon inertia.
Back to list of all published studies.
References:
1. Gilger MA, Wagner ML, Barrish JO, et al. New treatment
for rectal impaction in children: an efficacy, comfort and
safety trial of the pulsed-irrigated enhanced-evacuation
procedure. J Pediatr Gastroenterol Nutr 1994;18:92-5.
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evacuation: a new method for treating fecal impaction. Arch
Phys Med Rehabil 1991;71:935-6.
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