-
Postgraduate Medical Journal (October 1968) 54, 698-702.
Barium granuloma of the transverse colon
P. H. MCKEE C. H. S. CAMERON
The Department of Pathology, Queen's University, Belfast
SummaryA case of barium sulphate granuloma of the
transversecolon following gunshot wounds to the abdomen hasbeen
described. Scanning electron microscopy withelectron probe
microanalysis was used to confirm thepresence of barium sulphate
and the absence of lead orother elements related to the gunshot
wounds.
IntroductionBarium sulphate granuloma is a very rare compli-
cation of barium enemata. It was first described byBeddoe, Kay
and Kaye (1954). Since then, a varietyof reports have been
published (Levine and Simpson,1960; Caney and Stephens, 1973;
Lewis, Keisteinand Koss, 1975). It has been reported as occurring
inthe appendix (Chant, 1970) and as a complication ofbronchography
(Mital et al., 1975). The purpose ofthis paper is to describe a
case of barium sulphategranuloma of the transverse colon, occurring
as acomplication of a gunshot wound to the abdomen.
Clinical summaryThe patient was a 56-year-old male who was
admitted to the Royal Victoria Hospital following agunshot wound
to the chest and abdomen. The chestinjuries were repaired and, at
laparotomy, perfora-tion of the jejunum and laceration of the colon
wereidentified. The perforation and lacerations weresutured and a
proximal colostomy performed. Thepatient made a rapid recovery from
his extensiveinjuries.However, a barium enema performed 2
months
later revealed a stricture of the transverse colon fromthe
distal end of which was a small fistulous tract.Consequent upon
this, the area of narrowed colonwas removed and the colostomy
closed. Since thenthe patient's condition has been uneventful.
Material and methodsThe specimen of transverse colon taken
at
laparotomy was fixed in 10% formaldehyde. Follow-ing macroscopic
description, blocks were selectedand fixed in Bouin's fluid for
routine processing.Sections cut from the paraffin wax-embedded
blockswere stained with haematoxylin and eosin andexamined.
Serial material was obtained from the paraffinwax blocks and
processed for routine X-ray micro-analysis in the scanning electron
microscope(Cameron and McKee, 1978).The specimens were examined in
a Cambridge
Instrument S-600 Stereoscan Electron Microscope,equipped with a
link X-ray microprobe analysissystem utilizing a Kevex Si (Li)
detector. Operationalvoltage was 20 kV. Photographic records
wereobtained using Polaroid 33/4 x 43/4 land pack type105 and
Ilford Fp. 4 35 mm film.
ResultsThe gross specimen consisted of 12 cm of large
intestine. Approximately 5 cm from one limit wasan area of
stricture formation. Arising from this wasa 1-0 cm-long fistulous
tract. Histological examina-tion of sections taken from this area
revealed anormal mucosa and muscle coat. However, therewas quite
marked submucosal and serosal fibrosis.In addition, in the serosa
numerous macrophageswere seen containing greenish crystalloid
material(Figs 1 and 2).When viewed in the scanning electron
microscope,
the tissue structure was easily recognized and com-parable to
that observed in histological section (Fig.3). An area of high
electron activity was observed.This area showed little detail when
examined at upto x 1000 magnification (Fig. 4). Microprobeanalysis
of this and similar areas revealed counts asshown in Table 1. The
count time used was 100seconds.
TABLE 1. Teletype print-out of typical energy spectrum
Energy (eV) Integral Element
1-48 1041 Al172 335 Si2-26 53224 S2-62 3311 Cl4-44 36845 Ba4-84
13399 Ba(B,)5-16 1632 Ba(B.)5 52 964 Ba (yr)
0032-5473/78/1000-0698 $02.00 © 1978 The Fellowship of
Postgraduate Medicine
copyright. on June 22, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.54.636.698 on 1 October 1978. D
ownloaded from
http://pmj.bmj.com/
-
Case reports 699
-~~ ~ ~~~-i
N~~~~~~t~
W4le,140~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~f
FIG. 1. Low power view of serosal aspect of colon showing the
barium granuloma. HE, x 32.
4
WU7-
p.
FIG. 2. Higher power to show the macrophages containing granular
material. HE, x 80.
copyright. on June 22, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.54.636.698 on 1 October 1978. D
ownloaded from
http://pmj.bmj.com/
-
700 Case reports
Arl:
'~~~~~~~$r1~~~ am
priW-~~~~~~~~~~~~~~~~~~~~~I~~~~
N.S.,0
FIG. 3. Consecutive section to Fig. 1 viewed in the scanning
electron microscope, x 40.
'V.-ww v -~~~~~~~~~~~~~~A
*-tzb
FIG. 4. Higher power of Fig. 3, x 800.
copyright. on June 22, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.54.636.698 on 1 October 1978. D
ownloaded from
http://pmj.bmj.com/
-
Case reports
DiscussionBarium granuloma of the rectum is an exceedingly
rare condition. At present, twenty cases have beendescribed in
past publications (McDonald and Rowe,1976).
It has been suggested that previous rectal biopsy,excessive
intralumenal pressure, pre-existing diseasesuch as ulcerative
colitis, diverticulitis or carcinomamay be predisposing factors in
the development ofbarium granuloma following an enema.
Obviouslyimproper or an excessively forceful technique wouldalso be
important.The presence of barium granuloma should not
cause any serious clinical problems but if there wasexcessive
fibrosis it might cause some diagnosticdifficulties.As far as the
authors are aware, barium granuloma
has not been previously described from the transversecolon. This
case was of particular interest in that itdemonstrated an unusual
method of development ofsuch a lesion. It would seem most likely
that somebarium leaked along the fistulous tract at the site
ofprevious surgery and this became lodged in the serosaof the
bowel. Some accompanying fibrosis was seenbut as this was located
at the site of a fistula this ishardly surprising. In agreement
with other workers(Gaston, 1969) the present authors were surprised
tosee so little reaction.
It is peculiar that this condition should be so rare,considering
the numerous occasions when circum-stances could predispose to its
development. Reviewof past records in the Department of
Pathology,Queen's University, Belfast, reveals only one othercase
which was associated with diverticulitis of thesigmoid colon. The
rarity may be real, or apparentdue to failure to recognize the
lesion or disinclinationto report it.
It was obviously of great importance to identifyexactly the
nature of the material present in thegranuloma. It was considered
likely that it didrepresent barium sulphate from the enema butit
was also necessary to exclude any possibility of itsbeing related
to any parts of the ammunition thatcaused the initial wounds. It
was for this reason thatthe tissue was subjected to electronprobe
micro-analysis.Under optimum conditions, tissues for elemental
analysis would be frozen and unfixed or fixed ineither purified
glutaraldehyde or para-formaldehyde.The use of such fixatives as
Bouin's fluid, whichcontains approximately 0-015%O sulphur, should
beavoided as they introduce contaminants into thetissue. It must be
underlined that the choice ofBouin's fluid in this instance was
made as a routinehistological procedure before any thought was
givento microanalysis. However, the addition of such asmall
percentage of sulphur could not account for
the extremely high counts obtained in the tissue.A round of
ammunition consists of a bullet, the
cartridge case, the powder and the primer.Older ammunition
contained primers based on
mercury fulminate (Hg(CNO)2). Nowadays, however,the more modern
primer is composed of leadstyphnate (C6H(NO2)3O2Pb) and barium
nitrate(Ba(NO3)2) with the addition of two or more of thefollowing
compounds: tetrazene C1L8H12; lead di-oxide PbO2; lead
hypophosphite (Pb(H2PO2)2; anti-mony sulphide Sb2S3; calcium
silicide CaSi2; alu-minium powder Al.The powder of a round of
ammunition nowadays
is composed of organic nitro compounds (smokelesspowders).The
powder usually consists of a lead core
covered with a gilded metal jacket (copper alloyedwith 5-10% of
zinc). This jacket may be bare orplated with tin or, rarely,
nickel.
Spectrographic analysis of lead bullets shows thepresence of
other elements in traces: copper, bis-muth, silver and occasionally
thallium.The cartridge case is made in most instances of
brass. Within recent years the primer cap at the baseof the
cartridge has been nickel-plated. Occasionallyone also finds that
the brass case is nickel-plated.
Firearms discharge-residues consist of powder,primer,
lubricants, and metals. Analysis of suchresidues have shown that
the most frequentlyoccurring elements are lead, antimony, barium
andcopper. If one includes older ammunition, thenmercury must be
added to the list.
Thus, when a bullet is fired from a gun, it willhave residues,
from the primer, etc., on its surface.When the bullet penetrates
the clothing, skin, etc. ofthe victim, some of the residues from
its surface willbe transferred to the perimeter of the bullet
holeowing to the wiping action of the clothes, woundmargin, etc.
Nevertheless it is still possible that oncoming to its final rest
the bullet still may have apercentage of these substances
(residues) on its outersurface.
In the present case, the victim was apparently shotby a rifle
and none of the bullets remained withinhim. It was felt, however,
that it was just possiblethat the 'residues' or even minute
fragments of thebullet itself might have at least contributed to
thedevelopment of the granuloma.
It was for this reason, therefore, that electronprobe
microanalysis was undertaken.As can be seen from the results,
barium and
sulphur were present in very large amounts withmuch lesser
quantities of aluminium and chlorine.Lead, antimony, calcium,
copper, tin, nickel, bis-muth, silver and thallium were not
identified.
Thus, although the presence of barium could belinked with
firearms residues, the fact that the other
701
copyright. on June 22, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.54.636.698 on 1 October 1978. D
ownloaded from
http://pmj.bmj.com/
-
Case reports 702
commonly found elements, lead, antimony, andcopper, were not
identified would tend to exclude thepossibility of the granuloma
being due to residues.Similarly, the absence of lead, copper, zinc,
tin, andnickel would exclude the possibility of the granulomabeing
due to fragments of the bullet.The presence of aluminium is not as
easily ex-
plained and it was most likely due to contamination.It may have
come from the metallic top of the fixa-tive container or from the
specimen stub, although athick carbon planchet separated the
specimen fromthe surface of the mounting stub.
It was therefore considered that the elementsidentified could
only be attributed to the bariumsulphate of the enema.
AcknowledgmentsThe authors wish to express their appreciation to
Mr G.
Johnston, FRCS, for giving us access to the case. Dr R.
H.Williams and Mr A. W. Parke, Department of Physics, NewUniversity
of Ulster, Coleraine, for generous use of theirscanning electron
microscope facilities and expert technicalassistance.The authors
wish to acknowledge the help given by the
Ballistics Division, Department of Industrial and
ForensicScience, Ministry of Home Affairs, Northern Ireland.
ReferencesBEDDOE, H.L., KAY, S. & KAYE, S. (1954) Barium
granuloma
of the rectum: a report of a case. Journal of the
AmericanMedical Association, 154, 747.
CAMERON, C.H.S. & McKEE, P.H. (1978) A rapid method foruse
in the routine histopathological laboratory for theidentification
of deposits in tissue sections. Irish MedicalLaboratory Technology,
(in press).
CANEY, J.A. & STEPHENS, D.H. (1973) Intramural barium(barium
granuloma) of colon and rectum. Gastroenter-ology, 65, 316.
CHANT, Q.W. (1970) Barium appendicitis. Journal of theOklahoma
State Medical Association, 63, 570.
GASTON, E.A. (1969) Barium granuloma of the rectum.Diseases of
Colon and Rectum, 12, 241.
LEVINE, S. & SIMPSON, D.B. (1960) Barium sulphate granu-loma
of the rectum. American Journal of Proctology, 11,485.
LEWIS, J.W., KEISTEIN, M.D. & Koss, N. (1975)
Bariumgranuloma of the rectum. An uncommon complication ofbarium
enema. Annals of Surgery, 181, 418.
MCDONALD, C.C. & ROWE, J.R. (1976) Retrorectal
fistulasecondary to barium-abscess granuloma. Diseases of Colonand
Rectum, 19, 71.
MITAL, O.P., NARANG, R.K., MISRA, U.S., SACHAN, A.S.
&SAXENA, H. (1975) Barium granuloma following broncho-graphy: A
case report. Indian Journal of Chest Diseases,17, 55.
copyright. on June 22, 2021 by guest. P
rotected byhttp://pm
j.bmj.com
/P
ostgrad Med J: first published as 10.1136/pgm
j.54.636.698 on 1 October 1978. D
ownloaded from
http://pmj.bmj.com/