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  Table of Contents    
LETTER TO EDITOR  
Year : 2014  |  Volume : 57  |  Issue : 3  |  Page : 506-507
Barium granuloma mimicking carcinoma rectum: An unusual presentation


1 Department of Histopathology, PGIMER, Chandigarh, India
2 Department of Gastroenterology, PGIMER, Chandigarh, India

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Date of Web Publication14-Aug-2014
 

How to cite this article:
Gowda KK, Sinha SK, Chhabra P, Vaiphei K. Barium granuloma mimicking carcinoma rectum: An unusual presentation. Indian J Pathol Microbiol 2014;57:506-7

How to cite this URL:
Gowda KK, Sinha SK, Chhabra P, Vaiphei K. Barium granuloma mimicking carcinoma rectum: An unusual presentation. Indian J Pathol Microbiol [serial online] 2014 [cited 2019 Oct 24];57:506-7. Available from: http://www.ijpmonline.org/text.asp?2014/57/3/506/138807


Editor,

The barium enema remains a relatively safe "invasive" procedure. The complications include colonic perforation, venous embolization of barium and rarely barium granuloma (BG). BG can present as polypoid nodules or ulceroproliferative lesions of rectum and can be mistaken for adenocarcinoma. This report describes one such case of ulcerated rectal mucosal lesion endoscopically simulating carcinoma.

A 45-year-old female, known diabetic for 2 years on oral hypoglycemic agents with controlled blood sugar levels was referred to gastroenterologist with suspicion of rectal malignancy. The history revealed that patient was symptomatic for past 12 years with periumbilical and hypogastric crampy pain followed by passage of liquid to semisolid stools. Pain used to relieve after passage of stools. There was no history of radiation or migration of pain or night time frequency. General physical examination and systemic examination did not reveal any significant abnormalities. She had taken multiple consultatations with prescription of proton pump inhibitors, laxatives, and anti-depressants without much relief.

Gastroscopy was normal. She underwent barium enema 1 month prior to the present presentation, which was reported to be of normal study. Following to which, she developed bleeding per rectum and underwent sigmoidoscopy at an outside medical facility. The sigmoidoscopy revealed ulceroproliferative growth 4 cm beyond anal verge causing marked narrowing of the lumen, with scope being non-negotiable beyond the lesion. Subsequently patient underwent contrast enhanced computed tomography (CECT) abdomen, which revealed circumferential wall thickening of approximately 2.5 cm with the span of 8-9 cm with luminal narrowing and extension of growth into perirectal and presacral space.

With this background, the patient sought surgical consultation, where per-rectal examination confirmed an ulceroproliferative growth in rectum. A punch biopsy was taken from the lesion, histopathology of which revealed inflammatory granulation tissue with no evidence of malignancy. Following this, patient was referred to gastroenterologist in our institute. The patient was taken for colonoscopy after preparation with polyethylene glycol. The colonoscopy showed a 3 cm × 3 cm ulcer just beyond the anal verge with elevated margins, with the base of ulcer being hyperemic and slough at places [Figure 1]a. Rest of the visualized mucosa was normal till caecum. Multiple biopsies were taken from the ulcer. The histopathology revealed features of foreign body granuloma to barium particles (BG) which were seen are polarized refractile crystals under polarized light BG [Figure 1]c and d composed of ulcerated mucosa with ulcer base being formed by granulation tissue admixed with numerous histiocytes and few foreign body giant cells. Numerous refractile pale yellow crystals of barium sulfate were noted within histiocytes and also loosely lying intermixed with the inflammatory cells [Figure 2]. No malignancy was noted. The patient was given proton pump inhibitors and prokinetics and was reassured. A CECT done 4 months after the index CECT did not reveal any mass in the rectum. 9 months following the biopsy repeat sigmoidoscopy was done which showed normal study [Figure 1]b in the rectum. The patient is currently asymptomatic.

Barium granuloma was first described by Beddoe et al. way back in 1954. [1] <50 cases of BG having been reported in English literature. BG of rectum develops when Barium sulfate is forced through a discontinuity in rectal mucosa into subjacent layers. This break in continuity may result from intrinsic disease such as amoebiasis or ulcerative colitis or more commonly by injury from insertion of the enema tip, over inflation of the enema balloon, proctosigmoidoscopy, or rectal biopsy. [2] Extravasated barium incites variable inflammatory reaction starting with chemotaxis of polymorphonuclear leukocytes. Within a week chronic inflammatory reaction sets in characterized by varying degrees of fibrosis, macrophages and multinucleated foreign body giant cells with intra cytoplasmic barium sulfate crystals. [3] The inflammatory process gradually evolves into a typical granulomatous process, similar to our case.
Figure 1: Colonoscopic images showing ulceroproliferative lesion in the rectum (a) and total disappearance of the lesion on follow-up (b). The lesion on microscopy (H and E) showed granulati on tissue formati on (×200) (c). Refractile crystals of barium sulfate can be seen extracellularly and intracellularly (×400) (d) within histiocytes

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Figure 2: Numerous refractile crystals of barium sulfate crystals under light microscopy (100) (a) and the same crystals seen as polarized crystals under polarized microscope (100) (b)

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Time period between barium enema and detection of BG has ranged from immediate to 17 years. [4] It was 6 weeks in our patient. Our patient presented with bleeding per-rectum 4 weeks post enema, unlike most other patients of BG in whom pain abdomen was the most common mode of presentation. The majority of granulomas develop between 4 and 8 cm from the anal verge on either anterior or posterior wall, thus giving credence to assumption of enema catheter injury in its pathogenesis. In our patient, granuloma was located on anterior rectal wall within 8 cm of the anus and was endoscopically indistinguishable from carcinoma. BG assumes significance since it can mimic carcinoma of the rectum. Occult blood can be shed in the stool if lesion has ulcerated and digital examination may reveal shaggy, firm intrinsic mass. Endoscopic description of BG has been variable ranging from ulcers to nodules or plaques. There are few instances of lesions mimicking carcinoma. [5] Deep biopsies of such lesions, pelvic radiographs showing contrast material in the tissues, and an awareness of the existence and variable endoscopic manifestations of BG will obviate radical surgical procedures for an otherwise benign condition.

In any case of proximal (8 cm from the anal verge) ulcerating or polypoid rectal lesions with a history of a barium enema, BG should be considered in the differential diagnosis.

 
   References Top

1.
Beddoe HL, Kay S, Kaye S. Barium granuloma of the rectum; report of a case. J Am Med Assoc 1954;154:747-9.  Back to cited text no. 1
[PUBMED]    
2.
Szunyogh B. Enema injuries. Am J Proctol 1958;9:303-8.  Back to cited text no. 2
[PUBMED]    
3.
Kay S. Tissue reaction to barium sulfate contrast medium; histopathologic study. AMA Arch Pathol 1954;57:279-84.  Back to cited text no. 3
[PUBMED]    
4.
Carney JA, Stephens DH. Intramural barium (barium granuloma) of colon and rectum. Gastroenterology 1973;65:316-20.  Back to cited text no. 4
[PUBMED]    
5.
Rand AA. Barium granuloma of the rectum. Dis Colon Rectum 1966;9:20-32.  Back to cited text no. 5
[PUBMED]    

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Correspondence Address:
Kiran K Gowda
Department of Histopathology, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.138807

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