A Potential Hazard of Barium Cystoqraphy

CYSTOURETHROGRAPHY with visualization of the urethra during micturition is frequently hampered by the irritative effect of the contrast medium upon the urethra. Small children, particularly, often refuse to void. Bartley and Helander (l) believe Dionosil" is less irritating than Urokon.3 Doyle (2) and Hallgren et al. (3) have employed barium sulfate without complication. Their results prompted us to explore the use of barium sulfate as a contrast agent in children in an effort to secure more normal urethrograms. We wish to report a disturbing complication following reflux into the renal cortex and the subsequent appearance of barium casts in the urine. Methods In Children: Micropaque barium (<50 μ, particles) was utilized after its introduction into the obstructed renal pelvis of a pig failed to result in stone formation. The Micropaque was injected into the bladder as a sterile solution of 150 ml of medium in one liter of physiological saline. One hundred children with urinary tract symptoms were studied. Films were obtained during injection and while voiding. In Animals: Experimental studies to evaluate the effect of barium sulfate in the renal parenchyma were performed on a 250 lb. pig. The animal was anesthetized and the ureter exposed through a loin incision. The upper third of the ureter was ligated with a cloth umbilical tape, and 20 ml of Micropaque barium solution was injected proximal to the ligature. Tissue for histology was fixed in buffered formalin, dehydrated, and embedded in paraffin. Sections were cut at a thickness of 4 μ, and stained with hematoxylin and eosin. Results In Children: Studies on the first 99 children were uneventful and provided excellent visualization of the urethra without evidence of irritation. Cineradiographic and spot-film recordings were obtained in each case. In 17 children ureteral reflux was demonstrated, and in 4 renal reflux as well. Radiographs of the abdomen of the 4 children obtained twenty-four hours later failed to reveal any evidence of residual barium. The one-hundredth patient was a sixyear- old girl in whom the unexpected complication occurred. It was known that in the past this child had experienced reflux, as had several others employed in the study. Renal reflux at this time, however, was accompanied by an immediate transport of the barium into the renal parenchyma (Fig. 1). Periodic radiographs of the abdomen for the next six months showed the barium to be still present. Microscopic examination of sediment from twenty-four-hour urine collections disclosed renal tubular casts containing barium particles for approximately two months after cystography. The routine use of barium sulfate for cystography was discontinued immediately after the discovery of this complication.