Wilma C.

Diner, MD

Duodenal Perforation during Intubation

for Small Bowel Enema Study’
Use of the small bowel enema exami- T HE small bowel enema examination
nation (enteroclysis) is increasing, and (enteroclysis) was first described
numerous reports have attested to its in 1929 (1). It was used by only a few
value, but virtually no complications radiologists until it was popularized in
have been reported. The author de- the past decade (2-8). Numerous subse-
scribes a 72-year-old man undergoing quent reports attest to its value and in-
enteroclysis for weakness, anemia, creased usage (9-23), but very few side
and guaiac-positive stools in whom effects and virtually no complications
the duodenum was perforated during have been reported. We report here a
intubation. Radiologists should be serious complication that occurred dur-
aware of this potential complication, ing the intubation procedure.
and inexperienced people should be
supervised carefully during the proce-
dure.
CASE REPORT
A 72-year-old man, previously treated
Index terms: Duodenum, perforation, 73.458 for angina, was being evaluated for weak-
#{149}
Intestines, radiography, 74.1272 Radiology
#{149}
ness, iron deficiency anemia, and guaiac-
and radiologists, iatrogenic injury positive stools. Upper gastrointestinal
endoscopy revealed a hiatal hernia and
Radiology 1988; 168:39-41
duodenitis. Colonoscopy revealed diver-
ticulosis, hemorrhoids, and a small polyp,
which was removed. Because of the per-
sistence of occult blood in the stools, en-
teroclysis was scheduled.
Intubation was performed with a 12-F,
135-cm-long polyvinyl single-end-hole
catheter with guide wire (Herlinger mod-
ification of the Bilbao-Dotter tube [no.
SBD200]; Cook, Bloomington, Ind). A ra-
diology resident and a gastrointestinal ra- Figure 1. Lateral view shows barium col-
diology fellow were present. After some lection in retroperitoneal space. Enteroclysis
initial difficulty in traversing the hiatal tube is still in place.
hernia, the tube tip was maneuvered into
the second portion of the duodenum. The
guide wire extended just to the tip of the
end-hole catheter. Because the tube tip
could not be advanced beyond the second
portion of the duodenum, barium sulfate
was injected in order to confirm tube po-
sition (Fig 1). The tube did not seem to be
in its normal course, but the examiner be-
lieved that the barium had entered a di-
lated, probably obstructed duodenum. A
further 15 mL of barium followed by
some air was injected to evaluate the sup-
posed obstruction further. At this time it
was recognized that barium had entered
the retroperitoneal space rather than the
duodenum. At the time of the second bar-
ium injection, a radiology resident, a gas- Figure 2. Postoperative computed tomo-
trointestinal radiology fellow, and a staff graphic scan of the abdomen shows barium
radiologist were present. The tube was collection in the anterior pararenal space. A
then removed. drainage tube is in place.
After recognition of the perforation, a
surgical consultation was obtained, and
I From the Department of Radiology, Univer- the patient was operated upon on the erative endoscopy . The retroperitoneum
sity of Arkansas for Medical Sciences, 4301 W
same day. Extensive exploration revealed was irrigated and drained. A considerable
Markham, Slot 556, Little Rock, AR 72205. Re-
the barium in the right anterior pararenal amount of barium remained in the retro-
ceived January 7, 1988; revision requested Feb-
retroperitoneal space adjacent and inferi- peritoneal space (Fig 2). The patient’s
ruary 11; revision received March 4; accepted
March 23. Address reprint requests to the au- or to the duodenum. No perforation postoperative course was complicated by
thor. could be found by means of duodenal deep venous thrombosis and pulmonary
RSNA. 1988 mobilization, air insufflation, or intraop- embolism, for which an Amp!atz inferior

39
 reflux and vomiting were documented group of 56 patients with suspected
in one patient during procedure,
the partial small bowel obstruction evabuat-
making it an unsatisfactory study. One ed by means of the intubation infusion
patient with a high intestinal obstruc- method, no complications occurred
tion vomited and aspirated barium and (22,26). In a series of 1 1 similar pa-
gastric content, resulting in aspiration tients, Roedigen et al reported that one
pneumonia. A few others vomited after patient developed acute obstruction af-
gastric refiux but did not aspirate, and ten 2 days, necessitating operation.
their studies were completed. One pa- Multiple adhesions were found. It
tient complained of marked abdominal seems unlikely that the procedure was
distention during the procedure but in any way responsible (27). Caroline et
was discharged from the hospital the al studied 60 patients examined by
next day without complaints. means of enteroclysis with a final diag-
nosis of adhesive obstruction and did
not report any procedure-associated
DISCUSSION complications (28).
Allergic reactions rebated to barium
Perforation of the intestine by feed- examinations, and presumably caused
ing tubes of various kinds has been nec- by additives or glucagon, have not
ognized. The majority of cases involve been reported following enteroclysis.
perforation of the duodenum by the
Since they have occurred with upper
distal end of the tube in newborns. and lower gastrointestinal studies,
Figure 3. Abdominal radiograph obtained
This has been attributed to stiffening of there is no reason to believe they will
21/2 months after perforation and surgical
drainage. A large amount of barium remains polyvinyl tubes after 1 or more days of not occasionally be seen with entero-
in the retroperitoneal space and in the in- retention in the intestinal lumen (24). clysis as well (29-31).
guinal canal. Note the Greenfield inferior No cases of perforation occurring dun- Because of possible vomiting if duo-
vena cava filter (arrowhead). ing enteroclysis could be found in the denogastnic neflux occurs, we make ev-
literature. Sellink has been quoted as eny attempt to make sure the tip of the
warning against the possibility of pen- tube is positioned beyond the ligament
vena caval filter was inserted (Fig 3). The foration by the tube and/or guide wire of Treitz before the infusion is begun.
patient recovered and is now doing well, during enteroclysis, prompting at least Maglinte has designed a balloon tip
about 1 year later. one gastrointestinal radiologist not to tube for occlusion of the bowel lumen,
allow radiology residents to intubate preventing reflux. He routinely posi-
his patients without direct supervision tions the balloon in the proximal jeju-
COMPLICATIONS OF (D. Maglmnte, oral communication, num if the tip enters the jejunum neadi-
ENTEROCLYSIS 1987). by. If not, the balloon is left in the distal
In his review of gastrointestinal corn- duodenum. Both positions diminish
For the past several years, we have plications of radiobogic procedures, duodenogastnic reflu.x, although fur-
been using enteroclysis freely and fre- Gelfand does not mention enteroclysis, then decrease in refbu.x occurs and fasten
quently for radiologic evaluation of the nor does he report instances of penfora- infusion rates are possible if the bal-
small intestine. Except for the case re- tion of the duodenum during intuba- loon is in the proximal jejunum (32).
ported here, few complications have tion for hypotonic duodenography Infusion flow rates can be monitored
occurred. A few patients object to the (25). Maglinte has accumulated exten- by means of an electric motor-driven
passage of the tube, and an occasional sive experience with enteroclysis, hay-
pump. A uniform rate of approximately
one refuses to allow it. The tube occa- ing performed or supervised approxi- 75-85 mL/minute is usually adequate.
sionally enters the trachea on the first mately 6,000 cases. He has not had any If agents such as metacbopromide are
attempt. Cold sensations and an occa- cases of duodenal perforation (D. Mag- used to promote motility, fasten flow
sional frank chill occurred during our linte, oral communication, 1987). Sel- rates may be employed without pana-
early experience, when we mixed our link and Miller recommend that the byzing motility on resulting in duode-
own methylcellulose solution, using guide wire be shorter than the tube in nogastnic relfux (32-35).
ice water for the final dilution. We doc- order to prevent its extrusion through We report our unfortunate expeni-
umented small drops in body tempera- the side holes of the tube (8). Although ence to emphasize the ease with which
tune immediately after the procedure, our guides are the same length as the the tube penetrated the wall of a non-
the greatest drop being 1.7#{176}F.Since tube, providing a bit more control diseased duodenum and how easy it is
converting to commercially available when advanced to the tip, extrusion is to mistake the netropenitoneal position
methylcellubose solution that is diluted not possible, as the tubes have only a of the tube for the expected intnaduo-
with tap water, this has ceased to be a single end hole. The guide wire is cus- denal position. Perhaps more careful
problem. Anecdotally, patients are said tomanily kept pulled back 5-6 cm from attention to the possibility will prevent
to sometimes experience one or more the end of tube for flexibility in ma- a future similar occurrence. We recom-
loose bowel movements after the pro- neuvening the tube through the duode- mend careful supervision of the proce-
cedure. A review of all our examina- num. Selbink and Miller caution dunes when they are performed by in-
tions performed over a 1-year period against allowing the tube to enter a lat- experienced persons. The guide wine
failed to reveal the occurrence of diar- eral duodenal diverticulum and there- should be kept retracted 3-5 cm from
rhea documented in a single patient’s by altering the normal curved pathway the tip of the tube whenever a curve is
medical record, a fact that leads us to through the duodenum. Frequent stem- being negotiated. If the tube does not
believe it is a minor problem. In a ilization of the tubes results in stiffen- readily traverse the usual anatomic
group of these patients being studied ing, so that it becomes impossible to curves, no force should be applied. If
for suspected small intestinal obstruc- negotiate the curves, especially into the contrast material is injected in order to
tion, none complained of pain induced horizontal portion of the duodenum. evaluate the tube position, a water-sob-
by the procedure. Most patients do no- These authors state that perforation of uble agent should be used. U
tice a sensation of abdominal fullness the duodenum may occur but is rare.
during the procedure. Duodenogastnic They do not document such a case. In a

40 Radiology
#{149} July 1988
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