Case 33 Answer
History: abdominal pain. h/o prior abdominal surgery
Answer: Chronic Barium Peritonitis
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.
While Calcium is a possibility, it's all over the abdomen and pelvis and although some may be intranodal or granulomatous, some is clearly intraperitoneal - surrounding the splenic flexure of the colon and linear collections in the upper pelvis
Barium sulfate is (or was <wink>) 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).
Barium Peritonitis comes in two forms:
Acute - Barium causes 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 necessary antibiotic therapy for fecal/bacterial contamination.
Chronic - If not removed promptly, barium quickly clumps and adheres to parietal and visceral surfaces and becomes extremely difficult to remove. Fibrosis develops which can yield to repeated bowel obstructions.
Treatment is early laporatomy and extensive peritoneal washout.
Historic mortality rates are as high at 53%. However, despite our improved understanding of the underlying pathophysiology, more recent studies still show mortality rates in the 20-35% range, sometimes higher when there is associated bacterial peritonitis.
Take home message: It can be easy to see scattered hyperdense material throughout the abdomen and assume it is lymph node calcifications or retained barium within diverticula. I keep this case in mind to remind myself of the possibility and morbidty if it isn’t