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Rectal perforations after barium enema: a review.
Dis Colon Rectum. 2006 Feb; 49(2):261-71.DC

Abstract

PURPOSE

Rectal injuries during barium enema are rare but life-threatening complications. The last review about this subject was published more than ten years ago. In the present review, we present an overview on the subject and especially focus on changes in treatment strategies and developments of less risky visualization techniques.

METHODS

A literature search was performed in the PubMed library using the key words-barium enema, complications, peritonitis, and rectal perforation-as well as related articles and other references obtained from these articles.

RESULTS

The most frequent cause of perforation is iatrogenic and catheter-related. Other causes are related to weakness of the colorectal wall or obstruction. Five types of perforations have been described: 1) perforations of the anal canal below the levator; 2) incomplete perforations; 3) perforations into the retroperitoneum; 4) transmural perforations into adjacent viscera; 5) perforations into the free intraperitoneal cavity. Most incomplete perforations and one-half of the retroperitoneal perforations have minimal clinical signs. Intraperitoneal perforations lead to the most catastrophic course, starting with rectal bleeding and mild abdominal complaints. This is rapidly followed by progressive sepsis and peritonitis, and leads to a high mortality rate. Surgery is not always required for intramural or small retroperitoneal perforations. These can be treated conservatively and require surgical debridement only in case of large amounts of extravasation or abscesses. Surgical repair of large rectal mucosal lesions or anal sphincter lesions is advised. Perirectal abscesses require drainage. Intraperitoneal perforations with gross extravasation need immediate aggressive surgical treatment in a critical care setting, because the threat of shock is high. Intraperitoneal perforations, neglected perforations, gross barium extravasation, poorly prepared colon, and venous intravasation of barium are prognostically unfavorable. The severest late complication in intraperitoneal perforations is ileus. Meticulous technical performance of the barium enema is the most important factor in prevention.

CONCLUSIONS

Rectal perforations after barium enema are rare. The overall mortality rate decreased in recent decades from approximately 50 to 35 percent as the result of advances in supportive and intensive care. Because of these advances, more aggressive surgical strategies were undertaken. With the advent of endoscopy, less barium enemas are performed. Consequently, the absolute incidence of complications has decreased. It is expected that in the future barium enemas will be replaced by more sensitive and less risky techniques, such as CT colonography and magnetic resonance colonography.

Authors+Show Affiliations

Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands. pdf@home.nlNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

16328608

Citation

de Feiter, Peter W., et al. "Rectal Perforations After Barium Enema: a Review." Diseases of the Colon and Rectum, vol. 49, no. 2, 2006, pp. 261-71.
de Feiter PW, Soeters PB, Dejong CH. Rectal perforations after barium enema: a review. Dis Colon Rectum. 2006;49(2):261-71.
de Feiter, P. W., Soeters, P. B., & Dejong, C. H. (2006). Rectal perforations after barium enema: a review. Diseases of the Colon and Rectum, 49(2), 261-71.
de Feiter PW, Soeters PB, Dejong CH. Rectal Perforations After Barium Enema: a Review. Dis Colon Rectum. 2006;49(2):261-71. PubMed PMID: 16328608.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Rectal perforations after barium enema: a review. AU - de Feiter,Peter W, AU - Soeters,Peter B, AU - Dejong,Cornelis H C, PY - 2005/12/6/pubmed PY - 2006/5/24/medline PY - 2005/12/6/entrez SP - 261 EP - 71 JF - Diseases of the colon and rectum JO - Dis Colon Rectum VL - 49 IS - 2 N2 - PURPOSE: Rectal injuries during barium enema are rare but life-threatening complications. The last review about this subject was published more than ten years ago. In the present review, we present an overview on the subject and especially focus on changes in treatment strategies and developments of less risky visualization techniques. METHODS: A literature search was performed in the PubMed library using the key words-barium enema, complications, peritonitis, and rectal perforation-as well as related articles and other references obtained from these articles. RESULTS: The most frequent cause of perforation is iatrogenic and catheter-related. Other causes are related to weakness of the colorectal wall or obstruction. Five types of perforations have been described: 1) perforations of the anal canal below the levator; 2) incomplete perforations; 3) perforations into the retroperitoneum; 4) transmural perforations into adjacent viscera; 5) perforations into the free intraperitoneal cavity. Most incomplete perforations and one-half of the retroperitoneal perforations have minimal clinical signs. Intraperitoneal perforations lead to the most catastrophic course, starting with rectal bleeding and mild abdominal complaints. This is rapidly followed by progressive sepsis and peritonitis, and leads to a high mortality rate. Surgery is not always required for intramural or small retroperitoneal perforations. These can be treated conservatively and require surgical debridement only in case of large amounts of extravasation or abscesses. Surgical repair of large rectal mucosal lesions or anal sphincter lesions is advised. Perirectal abscesses require drainage. Intraperitoneal perforations with gross extravasation need immediate aggressive surgical treatment in a critical care setting, because the threat of shock is high. Intraperitoneal perforations, neglected perforations, gross barium extravasation, poorly prepared colon, and venous intravasation of barium are prognostically unfavorable. The severest late complication in intraperitoneal perforations is ileus. Meticulous technical performance of the barium enema is the most important factor in prevention. CONCLUSIONS: Rectal perforations after barium enema are rare. The overall mortality rate decreased in recent decades from approximately 50 to 35 percent as the result of advances in supportive and intensive care. Because of these advances, more aggressive surgical strategies were undertaken. With the advent of endoscopy, less barium enemas are performed. Consequently, the absolute incidence of complications has decreased. It is expected that in the future barium enemas will be replaced by more sensitive and less risky techniques, such as CT colonography and magnetic resonance colonography. SN - 0012-3706 UR - https://www.unboundmedicine.com/medline/citation/16328608/Rectal_perforations_after_barium_enema:_a_review_ DB - PRIME DP - Unbound Medicine ER -