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barium contraindications

On 98-01-29, Bates wrote:  ->
 >  You said barium is inert and no big deal to aspirate.  Do you have any
 >  references that I can pass along to some doctors.  They get hysterical

My kind friend just sent over a whole bunch of good, annotated references.
So I guess I'll simply forward most of them. Here goes:

Feinberg MJ, Kneble J, Tully J, Segall L. 1990. Aspiration and the elderly.
Dysphagia 5: 61-71.

  No proven relationship between aspiration of oral contents, particularly
water and barium and the development of respiratory disorders. Depends on
patient's general defence system and nutritional status. Aspiration
pneumonia extremely difficult to diagnose in living person.  Often confused
with fleeting infiltrates due to conditions such as congestive heart
disease in the elderly.
(Olle's comment: Aspiration pneumonia is never a radiological diagnosis,
either. The xray films don't include bacterial samples or microscopy... But
we can sometimes say that "the opacities found have an appearance that is
consistent with aspiration.")

Barium sulfate: a new (old) contrast agent for diagnosis of postoperative
esophageal leaks
Gollub MJ; Bains MS
Radiology, 202:360-2  1997
 To determine whether esophagography with use of barium alone is safe for
detection of postoperative leaks of the esophagus. A review was performed
of 29 postoperative esophagograms that showed 29 leaks in 12 patients. All
studies were performed with a 50% dilution of barium sulfate. Leak volumes
were calculated as the product (in cubic centimeters) of the length, width,
and height. The safety and efficacy of barium were determined on the basis
of development of mediastinitis and retention of barium in the mediastinum
that would interfere with subsequent patient care.  In 11 of the 12
patients, follow-up studies were performed 4-48 days (mean, 10.2 days)
after diagnosis. Leaks were 0.25-375 cm3 (mean, 31.4 cm3). In five of 17
(29%) follow-up procedures, small amounts of residual barium were
detectable on the scout radiograph, none of which interfered with
interpretation of the new images. During a follow-up period of 7-448 days
(mean, 226 days), no cases of mediastinitis were found.  Esophagography can
be performed safely with barium to rule out an anastomotic esophageal leak.
(Olle's comment: This was surprising but good news!)

Journal of the American Geriatrics Society
Vol. 45 No. 2
February 1997

 Aspiration of oral and gastric contents
as well as of foreign material into the tracheobronchial tree of older
patients often represents a life-threatening situation.
Barium sulfate is an agent used widely in the imaging of the
gastrointestinal tract and is not inherently toxic to lung tissue. The
enclosed chest radiograph exhibits aspirated barium outlining a
significant portion of the tracheobronchial tree of a 78-year-old woman
with head and neck malignancy who underwent a barium small bowel follow
through examination to investigate recurrent vomiting and abdominal
distention a few days previously. The patient took the barium per orum
and was not noted to choke or cough. However, this radiograph was
obtained 4 days later when the patient began to have a productive
cough, fever, and elevated white blood cell count. There is outlining
of her lower respiratory tract bilaterally, but especially in the right
lower lung field where a focal infiltrate can also be seen. Her sputum
culture grew oral flora and she responded well to
ticarcillin-clavulonic acid.
Figure 1. Aspirated barium sulfate outlining the lower
respiratory tract after a small bowel follow-through in an older woman.
An infiltrate is present in the right lower lung field.
Barium aspiration is noted occasionally on chest radiographs,
especially in patients with underlying anatomical or neurological
defects such as head and neck malignancy, esophageal stricture,
diverticulum, or fistula. Barium aspiration was noted in
approximately 10% of 94 debilitated patients when barium was
administered in liquid form over a 2 to 4-day period. This study noted
that barium aspiration was associated with coughing when the patients
ate or drank. The incidental finding of aspirated barium
on a chest radiograph in a patient with no history of aspiration may
help the clinician avoid expensive swallowing evaluations and institute
rigorous aspiration precautions, including tube feeding, especially in
patients with underlying illness.
Mark A. Marinella,MD
Wright State University School of Medicine
Dayton, OH
(Olle's comment: As you all know, tube feeding increases the risk of
aspiration of reflux material......)

Pulmonary Aspiration in a Long-term Care Setting:
and Laboratory Observations and An Analysis of Risk Factors
Neora Pick, MD, Anne McDonald, RN, Nancy Bennett, MD, Mildred Litsche,
MNS, RD, Linda Dietsche, RNC, Robert Legerwood, RPh, Richard Spurgas,
DDS, and F. Marc LaForce, MD.
To determine the incidence and risk factors associated
with aspiration in a high risk group in a long-term care setting.
 A prospective study of demographic, nutritional, clinical,
dental, and survival characteristics in 69 patients who suffered 98
aspiration events from May 1, 1990, to December 31, 1990. Demographic and
nutritional data from 192 patients who did not aspirate were collected
from September 1991 to December 1991.
Long-term care residents, most of whom were
neurologically debilitated.
The incidence of aspiration was measured and the
clinical and microbiological characteristics of aspiration-associated
nosocomial pneumonia described. Mortality and demographic, clinical, and
nutritional characteristics were compared between patients who aspirated
and those who did not.
 Twenty-five percent of the study group aspirated
during the 8-month observational period, and 56% of the aspiration events
progressed to roentgenographically proven cases of nosocomial pneumonia.
Six bacteremic episodes were documented, and results of sputum cultures
were consistent with mixed Gram-positive and Gram-negative infections.
During the study period, patients who aspirated were at three times the
risk of dying compared with patients who did not aspirate. Three years
later, only 17% of the original group of patients who aspirated were
still alive compared with 60% of the patients who had not aspirated.
Multivariate analysis identified
tube feeding, presence of a hyperextended neck or contractions,
malnutrition, and the use of benzodiazepines and anticholinergics as risk
Pulmonary aspiration is a common and serious event in
neurologically impaired long-term care patients. Some risk factors are
amenable to change.
J Am Geriatr Soc 44:763-768, 1996.

Dougle LA; Joore JC; Hendriks JJ; Martijn A; Knol K;
Mild sequelae 12 years following massive aspiration of barium sulfate in
the lungs
Ned Tijdschr Geneeskd
A twelve-year-old girl, who as a baby underwent an investigation of the
oesophagus and stomach with barium roentgen contrast fluid, during which
there was massive aspiration of barium contrast into the right lung, at
follow-up showed no abnormalities, apart from slight signs of peribronchial
granulomatosis or fibrosis. If there is an enhanced risk of  aspiration or
an oesophago-tracheal fistula is suspected it is better to use an isotonic
water-soluble contrast fluid.

Logemann JA; Roa Pauloski B; Rademaker A; Cook B; Graner D; Milianti F;
Beery Q; Stein D; Bowman J; Lazarus C; et al; 1992. Impact of the
diagnostic procedure on outcome measures of swallowing rehabilitation in
head and neck cancer patients.
Dysphagia; 7:179-186

This study was designed to determine whether swallow rehabilitation
outcomes were affected by the type of evaluation procedure utilized by the
clinician. The two evaluation techniques compared were the bedside
examination and videofluoroscopy (the modified barium swallow). Ten
institutions participated in this study, enrolling a total of 103 partial
laryngectomized patients, 21 in the bedside arm and 82 in the
videofluoroscopy arm. Data on recovery of oral intake were collected
weekly. All patients received an X-ray study of swallow at 3 months after
the operation. Mean time to oral intake of  food was significantly lower in
patients assessed with bedside examination. Overall swallow measures of
transit times and swallow efficiencies after 3 months revealed
significantly better function in the videofluoroscopy group. Results are
discussed in terms of the visibility of swallow physiology with the two
assessment techniques, the accuracy of therapy planning with the bedside
examination versus videofluoroscopy and the ability of head and neck cancer
patients to tolerate some aspiration without developing aspiration pneumonia.

Limitations and dangers of gastrografin swallow after esophageal and upper
gastric operations
Fan ST; Lau WY; Yip WC; Poon GP; Yeung C; Wong KK
Am J Surg, 155:495-7  1988
In a series of 135 patients who underwent esophageal and upper stomach
surgery, the incidence of anastomotic leakage was 20.4 percent. One hundred
four patients had either Gastrografin swallow or the methylene blue test to
evaluate anastomotic integrity before resumption of oral feeding. Both
tests were disappointing in that methylene blue failed to detect any case
of leakage and Gastrografin swallow could only detect three cases of
subclinical leakage. The high false-negative detection rate of Gastrografin
swallow might be related to the inferior radiographic detail provided by
this contrast medium. Aspiration of Gastrografin is potentially dangerous
and could be fatal. We believe that barium sulfate, which provides better
radiographic detail and is not so hazardous when aspirated, should be the
contrast medium of choice

Aspiration of barium contrast medium and its prevention
Szanto D; Barzo P; Jager M; Molnar L; Bordas M; Szucs G
Orv Hetil, 134:1969-72  1993
The authors noted aspiration bronchograms associated with barium-filling
study of the upper gastrointestinal tract in 58 patients involving basal
medial, anterior, lateral and posterior segments of the lower pulmonary
lobes, mammary segment of the middle lobe, and inferior lingula. In 75.9%
of patients (44 cases) the barium meal reached bilateral basal medial,
anterior and lateral segments. The 34 men and 24 women had a mean age of 69
years (range, 29-88 years). The aspiration was found 3.8-times more often
after age 50. A transient tertiary mobility disorder of the esophagus,
extrasystoles and tendency for collapse were found on barium-filling of
bronchi. The bronchi were lavaged with saline within 30 minutes  following
aspiration of the contrast medium

Acute pneumonitis caused by low density barium sulphate aspiration
Pracy JP; Montgomery PQ; Reading N
J Laryngol Otol, 107:347-8  1993
The aspiration of contrast medium during the investigation of swallowing
disorders is a well recognized hazard. It is therefore essential that the
contrast medium administered is non-irritant to the lungs. A case is
presented to illustrate the problems associated with the aspiration of a
relatively non-irritant contrast medium (barium sulphate).

The diagnosis of airway obstruction in children.
Stark J; Roesler M; Chrispin A; de Leval M
J Pediatr Surg, 20:113-7  1985
Airway obstruction in children has many causes. Although vascular rings may
have early onset of symptoms there was considerable delay in establishing
the correct diagnosis. Barium swallow is diagnostic. Other tests, such as
angiocardiography, bronchoscopy, bronchography, and lung scan are usually
unnecessary. Pulmonary sling is a less common cause of vascular
obstruction. Barium swallow showing anterior indentation at the level of
the pulmonary hilum is diagnostic. Cysts and tumors are other causes of
severe airway obstruction. The diagnostic and operative problems in three
patients are discussed as examples. It is concluded that barium swallow is
the most important single investigation in the evaluation of airway

Experimental evaluation of various available contrast agents for use in the
upper gastrointestinal tract in case of suspected leakage. Effects on lungs.
Ginai AZ; ten Kate FJ; ten Berg RG; Hoornstra K
Br J Radiol, 57:895-901  1984
The reactions of seven contrast agents--pure barium sulphate, Micropaque,
Gastrografin, Dionosil, Hytrast, Amipaque and Hexabrix--on the bronchi and
lungs of rats were studied. This work was undertaken to find a safe
gastrointestinal contrast agent for use in post-operative patients where
aspiration may be an accompanying risk. Amipaque and Hexabrix produced no
significant histological reaction in the lungs and would, therefore, appear
to be suitable for use in such cases

Barium sulfate bronchography. Report of a complication.
Buschman DL
Chest, 99:747-9  1991
Alveolarization of the barium sulfate and subsequent retention of barium
sulfate for years was demonstrated in three patients in whom dilute
suspension of barium sulfate in water was used for bronchography.
Pathologic examination in one patient showed barium sulfate within
macrophages in the alveolar spaces and walls and in the perivascular and
peribronchial interstitium. Since the residual barium sulfate interferes
with imaging procedures of the lungs, it represents an unwanted event in
patients with pulmonary disease. High-resolution computed tomography is the
preferred method of evaluating for bronchiectasis. If bronchogram is
performed, it should be performed after bronchoscopy using oily
propyliodone (Dionosil).

Hope this helps. Thank my helpful and well-read friend!


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