Thread by @RyanChristieMD

Wet Read Case 33

Special case for hitting 1000 followers! Thank you all!

Hx: abdominal pain

Any past medical hx? Diagnosis?

Professional gif responses only please. No spoilers! wetread.org #WetreadCow #FOAMrad #FOAMed #radres #errad #bodyrad @RyanBPetersonMD

Another view may be helpful.

Hoping everyone is safe and healthy!

@StefanTigges @ER_Rad_Hanna @AdamSingerMD

I think this is a tough one especially without windowing/leveling but what or should I say where is the abnormality?

Lots of high density material right? But hopefully these images show you that this material is NOT within the GI tract.

So what it is?

Answer: Chronic Barium Peritonitis

Ca+ is possible, but it's all over the abdomen and pelvis and although some may be LNs/granulomas, some is intraperitoneal - surrounding the splenic flexure and linear collections in the upper pelvis #FOAMmed #FOAMrad #bodyrad #radres

Barium sulfate is (or was 😉) a commonly used hyperdense oral contrast agent used for intraluminal evaluation of the GI tract

Unfortunately, if leaked into the abdominal cavity it can induce an inflammatory response (even in the absence of leakage of fecal material).

So Barium sulfate SHOULD NOT be used in the setting where there is known or concern for GI perforation.

Two forms of BP:

Acute BP- a chemical induced inflammation. This can cause large volume exudative ascites actually resulting in severe hypovolemia requiring aggressive fluid resuscitation😮. This is in addition to any antibiotic therapy for fecal 💩/bacterial contamination.

Chronic BP- If not removed promptly, barium quickly clumps and adheres to parietal and visceral surfaces and becomes extremely difficult to remove. Fibrosis develops which then results in repeated episodes of bowel obstruction.

Treatment is early laparotomy and extensive peritoneal washout 🌊. + Volume resuscitation if necessary

Historic mortality rates are as high at 53%. However, even with our improved understanding of the underlying pathophys, more recent studies still show mortality rates in the 20-35% range 😮, sometimes higher when there is associated bacterial peritonitis.

⭐️Take home message: It is easy to see scattered hyperdense material throughout the abdomen and assume it is lymph node calcs or retained barium within diverticula. It likely is! But I try to keep this case in mind to remember the possibility and morbidity of it being elsewhere