AJR 2003; 180:490-492
© American Roentgen Ray Society
Barium Impaction Therapy for Refractory Colonic Diverticular Bleeding
Nobuyuki Matsuhashi1,
Masaaki Akahane2 and
Atsushi Nakajima3
1 Department of Gastroenterology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku,
Tokyo 113-8655 Japan.
2 Department of Radiology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo
113-8655 Japan.
3 Third Department of Internal Medicine, Yokohama City University, 3-9 Fukuura,
Kanazawa-ku, Yokohama 263-0004 Japan.
Received May 13, 2002;
accepted after revision June 18, 2002.
Address correspondence to N. Matsuhashi.
Introduction
Diverticular hemorrhage is a common and important cause of colonic
bleeding. Acute bleeding is often treated endoscopically or angiographically,
and intractable bleeding is treated surgically. The disease is benign,
however, and patients are often elderly and therefore at high risk for surgery
[1,
2]. We present a patient with
colonic diverticular bleeding that could not be treated endoscopically or
angiographically but was successfully controlled by a newly designed barium
impaction therapy using a high concentration of barium sulfate solution
containing epinephrine.
Case Report
A 71-year-old woman presented with sudden painless massive bright-red
rectal bleeding. She was transferred to our hospital 12 hr after the onset of
the bleeding. Oral intake was stopped and 4 U of blood were transfused.
Emergent colonoscopy with a purge of polyethylene glycol—salt solution
was considered, but the patient could not ingest the solution. An emergent
colonoscopy was performed 4 hr after admission and after three courses of
colon irrigation with saline. Dark red material was observed throughout the
colon, and many diverticula were noted in the ascending, transverse, and
sigmoid colons. The ileal lumen was free of blood. Active bleeding was absent,
and the source of the bleeding could not be determined.
The patient was treated conservatively with fasting and infusion therapy.
Four days later, however, bright-red rectal bleeding recurred and she
presented in hemorrhagic shock. After blood transfusion and a purge with
polyethylene glycol—salt solution, another colonoscopy was performed.
Again, dark red material was observed throughout the colon, but careful
endoscopic examination failed to visualize a source of active bleeding,
vessels, or adherent clots. No angiodysplasia was present in the colon. The
color of the intraluminal material tended to be slightly lighter in the
ascending colon than in the distal colon, which suggested that the bleeding
was from one of the ascending colon diverticula. Conservative therapy,
including transfusion of blood and IV hyperalimentation, was continued.
Two days later, the patient began bleeding again. Angiography and
99mTc—human serum albumin scintigraphy were performed to
determine the source of bleeding, but both failed to do so. Rectal bleeding
continued intermittently, and further blood transfusion was necessary.
Barium impaction therapy was performed the next day. Glucagon (Glucagon G
Novo; Novo Nordisc Pharma, Tokyo, Japan; 1 IU) was administered IV before
therapy as an antispasmodic. Barium sulfate solution (400 mL of 200 g/100 mL
solution; 200 w/v percentage) was prepared by mixing 220 g of water and 800 g
of barium sulfate powder and shaking. One milligram of epinephrine was poured
into the barium solution, and the solution was shaken again. The solution was
administered using a double-balloon enema tip (Balloon Enema Catheter; Create
Medic, Yokohama, Japan). Then an additional 400 mL of 200 w/v percentage
barium was administered. After we confirmed that the ascending colon and cecum
were filled with barium, the enema tip was clamped and the patient's position
was changed every 5 min (prone, left lateral, supine, and right lateral
positions) for 2 hr. The patient remained in the radiology department the
entire time. The enema tip was then withdrawn. Her blood pressure was
monitored every 3 min, but no significant change was noted. After this
procedure, hematochezia stopped. Several barium-impacted diverticula were
visible in an abdominal radiograph 6 days later
(Fig. 1). Ten units of blood
were required for transfusion during the entire course of the disease, but
surgery was avoided. Oral feeding was resumed 8 days after the impaction
therapy, and bleeding did not recur. The patient is now well and free of
bleeding 13 months after the barium impaction therapy.
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Fig. 1. —71-year-old woman with bleeding diverticulum in ascending
colon. Abdominal radiograph taken 6 days after barium impaction therapy shows
that barium remains in colon, appendix, and colonic diverticula. Refractory
bleeding stopped after therapy.
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Discussion
Hemorrhage from colonic diverticula is usually treated conservatively by
bed rest, fasting, and infusion therapy because spontaneous hemostasis is
common. Approximately 25% of patients with stopped bleeding, however, present
with rebleeding [1]. Specific
interventions for diverticular bleeding include endoscopic and angiographic
approaches. Injection of an epinephrine solution, use of a fibrin sealant, and
hemoclips have been reported as effective endoscopic interventions
[3]. Heater probe and argon
plasma coagulation are also feasible
[4], but the walls of the
diverticula are thin and can be easily perforated. Target suctioning and band
ligation have also been reported. The endoscopic approach is especially useful
when the source of bleeding can be visualized endoscopically
[1]. However, in patients with
colonic diverticulosis the source of bleeding is often difficult to determine
endoscopically. Urgent colonoscopy with an oral purge contributes to an exact
endoscopic diagnosis and effective intervention
[1]. However, the oral purge is
not always possible, particularly in elderly patients, who have an increased
incidence of diverticular hemorrhage.
In some cases, angiography can detect active bleeding and achieve
hemostasis by embolization or the infusion of vasoconstrictors such as
vasopressin [2,
5], but it is difficult to
detect the source of bleeding using this approach unless a moderate degree of
active bleeding is present at the time of the procedure. In addition,
rebleeding is common after the cessation of vasoconstrictor therapy
[2], and the use of
vasoconstrictors is often associated with cardiovascular complications. On the
other hand, embolization of a colonic lesion is prone to result in intestinal
infarction [6]. Thus, some
cases cannot be controlled safely by endoscopic or angiographic measures, and
surgical intervention is necessary. The development of another noninvasive
therapy would be beneficial, especially if it is safe and easy to perform.
Barium sulfate is used extensively as a contrast medium. It is safe and
does not injure the gastrointestinal mucosa. Barium sulfate sometimes becomes
solid in the gut and can occasionally cause constipation, especially when it
remains in the gut for a prolonged period. Barium impaction in colonic
diverticula or appendixes often persists for weeks, months, and sometimes
years after the barium examination without causing mucosal injury. These facts
suggest that the agent could be used therapeutically in diverticular
hemorrhage. We believe that the barium fills the bleeding diverticulum,
tamponades it by intraluminal pressure, protects the injured mucosa from fecal
materials, solidifies, and persists for a long time. Indeed, two reports have
suggested the efficacy of barium enema in the treatment of diverticular
bleeding [7,
8]. Details of the method were
not presented in those reports, but 53 of 63
[7] and 47 of 49
[8] episodes of acute
diverticular bleeding are reported to have been stopped by therapeutic barium
enema. Rebleeding occurred significantly less frequently in barium
enema—treated patients (16%) than in conservatively treated patients
(43%) [7].
In our patient, several modifications were applied to enhance the
effectiveness of the therapy. To increase viscosity and facilitate
solidification, we prepared the barium solution as 200 w/v percentage, a
concentration much higher than that used in barium enema examination (
70
w/v percentage). In addition, epinephrine was added to the solution for
vasoconstrictive effect, especially at the site of the mucosal break. The
usual subcutaneous or intramuscular dose of epinephrine for asthma or
hypotension is 0.2-1 mg. Because the absorbability of epinephrine in a barium
solution administered into the colon was unknown, and we could not completely
rule out possible adverse effects including sudden hypertension, pulmonary
edema, ventricular fibrillation, or brain hemorrhage, the dose of epinephrine
was determined to be 1 mg, the upper limit for the usual subcutaneous or
intramuscular injection. After the colon and diverticula were filled with the
barium solution, the enema tip was clamped so that the solution would be
retained in the colon, and the patient's position was changed frequently to
ensure filling of each diverticulum. A double-balloon enema tip was used
because the patient was elderly and it might have been hard for her to remain
continent throughout the treatment with no balloon or a single-balloon
catheter. Both the rectal and anal cuffs were inflated, and the patient could
well tolerate the treatment without incontinence.
It might be necessary to monitor blood pressure when epinephrine is added
to the barium solution, because epinephrine could bring about adverse effects
as we have discussed. Especially patients with known cardiopulmonary disorder
should be treated with care. In our patient, however, no significant change in
blood pressure occurred during the therapy. Otherwise, this procedure is
thought to be safe.
This is a single case report, but the fact that the highly refractory
intermittent bleeding stopped after the barium impaction therapy is
impressive. The procedure is safe and easy to perform. A controlled study to
establish the feasibility of this therapy in colonic diverticular hemorrhage
is necessary. Barium impaction therapy might be considered in patients with
recurrent or massive colonic diverticular bleeding that cannot be controlled
by endoscopy or angiography. In fact, we have successfully used this same
approach to control the bleeding in another similar patient in our
institution.
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Introduction
Case Report
