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

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FIG. 1. Low power view of serosal aspect of colon showing the barium granuloma. HE, x 32.

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FIG. 2. Higher power to show the macrophages containing granular material. HE, x 80.

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FIG. 3. Consecutive section to Fig. 1 viewed in the scanning electron microscope, x 40.

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FIG. 4. Higher power of Fig. 3, x 800.

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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

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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.

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