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triglycerides&#44; 1&#46;12 g&#47;L&#59; urea&#44; 8&#46;6 mmol&#47;L&#59; creatinine&#44; 44&#46;2 mmol&#47;L&#59; total proteins&#44; 54 g&#47;L&#59; albumin&#44; 39 g&#47;L&#59; total bilirubin&#44; 17&#46;1 mmol&#47;L&#59; calcium&#44; 2&#46;0 mmol&#47;L&#59; sodium&#44; 147 mmol&#47;L&#59; potassium&#44; 3&#46;8 mmol&#47;L&#59; lactate dehydrogenase&#44; 360 U&#47;L&#59; glutamic pyruvic transaminase&#44; 20 U&#47;L&#59; glutamic oxalic transaminase&#44; 24 U&#47;L&#59; gamma glutamyl transferase 11 U&#47;L&#59; alkaline phosphatase&#44; 140 U&#47;L&#59; amylase&#44; 106 U&#47;L&#59; iron&#44; 1&#46;8 &#181;g&#47;L&#59; ferritin&#44; 5 &#181;g&#47;L&#46; The result of the analysis for blood in feces was positive&#46;</p><p class="elsevierStylePara">A chest x-ray gave normal results&#46; A gastroscopy was carried out and showed acute erosive duodenitis&#46;</p><p class="elsevierStylePara"> Following diagnosis of iron-deficiency anemia a barium enema examination was carried out and the contrast medium was accidentally administered into the vagina&#44; which tore at the side&#46; The fluoroscopy showed venous intravasation of barium&#46; The examination was discontinued and a chest x-ray revealed pulmonary barium embolization &#40;Figure&#41;&#46; The patient complained of dizziness and had signs of hypotension and shivering&#44; followed by fever of 38&#186;C&#46; The symptoms abated after administration of intravenous antibiotics and the vaginal tear was repaired surgically&#46; The results of analysis at this time were prothrombin time 100&#37;&#59; activated partial thromboplastin time 30&#47;30 s&#59; fibrinogen&#44; 2&#46;56 g&#47;L&#59; positive for fibrinogen degradation products &#40;80 &#181;g&#47;mL&#41;&#59; platelets&#44; 149x10<span class="elsevierStyleSup">9</span>&#47;L&#46; Tests for barium in the blood and urine were negative&#46;</p><p class="elsevierStylePara"><img src="260v39n11-13053347tab01.gif"></img></p><p class="elsevierStylePara">Figure&#46; Amplified image showing a barium particle in greater detail&#46;</p><p class="elsevierStylePara">On entering the circulatory system barium may cause shivering&#44; fever&#44; prolonged hypotension or shock&#44; and disseminated intravascular coagulation&#44; all produced by the sepsis when material enters with the barium&#46; Cultures of barium samples grow colonies of <span class="elsevierStyleItalic"> Escherichia coli&#44; Pseudomonas aeruginosa&#44;</span> and <span class="elsevierStyleItalic">Aerobacter</span> and <span class="elsevierStyleItalic">Flavobacterium</span> sp&#46; as well as very high concentrations of endotoxin&#46; This may activate the tissue factor and consequently the kallikrein-kinin system&#46; Barium <span class="elsevierStyleItalic">in vitro</span> causes the production of bradykinin&#44;<span class="elsevierStyleSup">1</span> which contributes to the before-mentioned effects&#46;</p><p class="elsevierStylePara"> Although soluble barium salts are absorbed by the digestive tract and enter the circulatory system producing hypokalemia&#44; cardiac arrythmia&#44;<span class="elsevierStyleSup">2&#44;3</span> and renal failure&#44;<span class="elsevierStyleSup">4</span> barium sulfate is not absorbable or soluble and does not have such toxic effects&#46; When barium reaches the lungs it can cause a clinical picture of pulmonary embolism with dyspnea&#44; tachypnea&#44; cough&#44; or acute pulmonary edema&#46; Barium can be detected in the liver and the lungs by simple x-ray and also by computed tomography&#46;<span class="elsevierStyleSup">5</span> The mortality rate for this condition is high&#58; of the 17 cases we reviewed in the literature&#44; 10 ended in death&#46; The condition was more serious when systemic circulation was affected&#44; with death occurring in 8 patients out of 11&#44; as opposed to 1 patient out of 6 when portal circulation was affected&#46; The mortality rate may also have depended on the quantity of barium particles involved&#44; as in surviving patients the amount of barium that entered the circulatory system was less than 5 mL&#46;<span class="elsevierStyleSup">5&#44;6</span> In surviving patients barium can be detected in images of the affected organs up to several months later&#44; even when the patient feels well&#46; In the case we describe barium was still being detected on chest x-rays some 7 months after the accident although the particles were smaller and had decreased in number&#59; one of them even seemed to be forming a granuloma&#46;</p><p class="elsevierStylePara"> Autopsies performed on patients who have died have shown swollen Kupffer cells and endothelial cells in various organs&#44; and inspection of cells under an electron microscope has revealed uniformly electrodense granules of various sizes&#46; It therefore seems that barium is in part purified by the reticuloendothelial system&#46;</p><p class="elsevierStylePara"> Little is known about how to treat this condition because of the scarcity of reported cases&#46; Given the pathogenesis of the process we propose the early administration of antibiotics that combat intestinal flora&#46; If hypotension or shock and disseminated intravascular coagulation appear&#44; they can be corrected using intravenous fluids&#44; inotropic drugs&#44; 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Pulmonary Embolism Caused by a Barium Enema
Embolia pulmonar por bario
S. Macedaa, A. Gonzálezb, F. Ladoc
a Pediatría de Atención Primaria, Centro de Salud de Monforte, Monforte, Lugo, Spain.
b Servicio de Radiología, Hospital de Monforte, Monforte, Lugo, Spain.
c Servicio de Medicina Interna, CHUS, Santiago de Compostela, La Coruña, Spain.
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"> To the editor&#58;</span> One of the complications that may arise when a contrast medium is applied by enema is venous embolism caused by barium intravasation into the venous system either from the colon &#40;facilitated by the existing pathological condition&#41; or from the vagina after tearing during accidental administration of the contrast medium there&#46; The barium can be transported through the venous or portal circulation systems and the lungs and liver can act as filters&#44; although barium may also pass through the lungs and enter other organs&#46;</p><p class="elsevierStylePara">We report a case in which a contrast medium was accidentally placed in the patient&#39;s vagina and caused a tear&#44; resulting in pulmonary embolism due to barium&#46;</p><p class="elsevierStylePara">The patient was a 62 year-old woman who presented with exercise-related dyspnea&#44; palpitations&#44; and nausea&#46; Her previous medical history only showed occasional use of salicylates for headaches&#46;</p><p class="elsevierStylePara">The physical examination revealed blood pressure to be 140&#47;70 mm Hg&#44; temperature 36&#186;C&#59; mucous membranes and skin were pallid&#46; Cardiopulmonary auscultation and abdominal palpation gave normal results&#46; The digital rectal examination showed dark stool &#40;the patient was taking iron&#41;&#46; The results of the complementary tests were as follows&#58; leukocytes&#44; 11x10<span class="elsevierStyleSup">9</span>&#47;L&#59; hematin&#44; 2&#46;08x10<span class="elsevierStyleSup">12</span>&#47;L&#59; hemoglobin 1&#46;02 mmol&#47;L&#59; hematocrit&#44; 19&#37;&#59; mean corpuscular volume&#44; 66 fL&#59; mean corpuscular hemoglobin&#44; 0&#46;31 pg&#59; platelets&#44; 191x10<span class="elsevierStyleSup">9</span>&#47;L&#59; red blood cell sedimentation rate&#44; 25 mm&#59; glucose&#44; 6&#46;1 mmol&#47;L&#59; cholesterol&#44; 4&#46;4 mmol&#47;L&#59; triglycerides&#44; 1&#46;12 g&#47;L&#59; urea&#44; 8&#46;6 mmol&#47;L&#59; creatinine&#44; 44&#46;2 mmol&#47;L&#59; total proteins&#44; 54 g&#47;L&#59; albumin&#44; 39 g&#47;L&#59; total bilirubin&#44; 17&#46;1 mmol&#47;L&#59; calcium&#44; 2&#46;0 mmol&#47;L&#59; sodium&#44; 147 mmol&#47;L&#59; potassium&#44; 3&#46;8 mmol&#47;L&#59; lactate dehydrogenase&#44; 360 U&#47;L&#59; glutamic pyruvic transaminase&#44; 20 U&#47;L&#59; glutamic oxalic transaminase&#44; 24 U&#47;L&#59; gamma glutamyl transferase 11 U&#47;L&#59; alkaline phosphatase&#44; 140 U&#47;L&#59; amylase&#44; 106 U&#47;L&#59; iron&#44; 1&#46;8 &#181;g&#47;L&#59; ferritin&#44; 5 &#181;g&#47;L&#46; The result of the analysis for blood in feces was positive&#46;</p><p class="elsevierStylePara">A chest x-ray gave normal results&#46; A gastroscopy was carried out and showed acute erosive duodenitis&#46;</p><p class="elsevierStylePara"> Following diagnosis of iron-deficiency anemia a barium enema examination was carried out and the contrast medium was accidentally administered into the vagina&#44; which tore at the side&#46; The fluoroscopy showed venous intravasation of barium&#46; The examination was discontinued and a chest x-ray revealed pulmonary barium embolization &#40;Figure&#41;&#46; The patient complained of dizziness and had signs of hypotension and shivering&#44; followed by fever of 38&#186;C&#46; The symptoms abated after administration of intravenous antibiotics and the vaginal tear was repaired surgically&#46; The results of analysis at this time were prothrombin time 100&#37;&#59; activated partial thromboplastin time 30&#47;30 s&#59; fibrinogen&#44; 2&#46;56 g&#47;L&#59; positive for fibrinogen degradation products &#40;80 &#181;g&#47;mL&#41;&#59; platelets&#44; 149x10<span class="elsevierStyleSup">9</span>&#47;L&#46; Tests for barium in the blood and urine were negative&#46;</p><p class="elsevierStylePara"><img src="260v39n11-13053347tab01.gif"></img></p><p class="elsevierStylePara">Figure&#46; Amplified image showing a barium particle in greater detail&#46;</p><p class="elsevierStylePara">On entering the circulatory system barium may cause shivering&#44; fever&#44; prolonged hypotension or shock&#44; and disseminated intravascular coagulation&#44; all produced by the sepsis when material enters with the barium&#46; Cultures of barium samples grow colonies of <span class="elsevierStyleItalic"> Escherichia coli&#44; Pseudomonas aeruginosa&#44;</span> and <span class="elsevierStyleItalic">Aerobacter</span> and <span class="elsevierStyleItalic">Flavobacterium</span> sp&#46; as well as very high concentrations of endotoxin&#46; This may activate the tissue factor and consequently the kallikrein-kinin system&#46; Barium <span class="elsevierStyleItalic">in vitro</span> causes the production of bradykinin&#44;<span class="elsevierStyleSup">1</span> which contributes to the before-mentioned effects&#46;</p><p class="elsevierStylePara"> Although soluble barium salts are absorbed by the digestive tract and enter the circulatory system producing hypokalemia&#44; cardiac arrythmia&#44;<span class="elsevierStyleSup">2&#44;3</span> and renal failure&#44;<span class="elsevierStyleSup">4</span> barium sulfate is not absorbable or soluble and does not have such toxic effects&#46; When barium reaches the lungs it can cause a clinical picture of pulmonary embolism with dyspnea&#44; tachypnea&#44; cough&#44; or acute pulmonary edema&#46; Barium can be detected in the liver and the lungs by simple x-ray and also by computed tomography&#46;<span class="elsevierStyleSup">5</span> The mortality rate for this condition is high&#58; of the 17 cases we reviewed in the literature&#44; 10 ended in death&#46; The condition was more serious when systemic circulation was affected&#44; with death occurring in 8 patients out of 11&#44; as opposed to 1 patient out of 6 when portal circulation was affected&#46; The mortality rate may also have depended on the quantity of barium particles involved&#44; as in surviving patients the amount of barium that entered the circulatory system was less than 5 mL&#46;<span class="elsevierStyleSup">5&#44;6</span> In surviving patients barium can be detected in images of the affected organs up to several months later&#44; even when the patient feels well&#46; In the case we describe barium was still being detected on chest x-rays some 7 months after the accident although the particles were smaller and had decreased in number&#59; one of them even seemed to be forming a granuloma&#46;</p><p class="elsevierStylePara"> Autopsies performed on patients who have died have shown swollen Kupffer cells and endothelial cells in various organs&#44; and inspection of cells under an electron microscope has revealed uniformly electrodense granules of various sizes&#46; It therefore seems that barium is in part purified by the reticuloendothelial system&#46;</p><p class="elsevierStylePara"> Little is known about how to treat this condition because of the scarcity of reported cases&#46; Given the pathogenesis of the process we propose the early administration of antibiotics that combat intestinal flora&#46; If hypotension or shock and disseminated intravascular coagulation appear&#44; they can be corrected using intravenous fluids&#44; inotropic drugs&#44; and the usual measures taken in these situations&#46; Surgical repair of lesions should not be delayed&#46;</p>"
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Article information
ISSN: 15792129
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2015 May 48 12 60
2015 April 31 8 39
2015 March 47 13 60
2015 February 30 2 32
2015 January 42 3 45
2014 December 45 5 50
2014 November 39 6 45
2014 October 48 7 55
2014 September 40 5 45
2014 August 52 9 61
2014 July 39 7 46
2014 June 45 6 51
2014 May 52 6 58
2014 April 45 5 50
2014 March 61 8 69
2014 February 49 7 56
2014 January 31 8 39
2013 December 43 8 51
2013 November 26 3 29
2013 October 31 7 38
2013 September 30 7 37
2013 August 48 8 56
2013 July 52 9 61
2013 June 39 5 44
2013 May 29 5 34
2013 April 26 4 30
2013 March 9 1 10
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