S3699 When Diagnosis Becomes the Problem: Retained Barium Contrast as a Contributor to Small Bowel Obstruction

Introduction: Small bowel obstruction (SBO) is a common surgical emergency, especially in the elderly, accounting for about 15% of acute abdominal pain admissions. While typically caused by adhesions, hernias, or malignancies, less common factors like retained contrast material may be overlooked. Barium sulfate, used in imaging such as modified barium swallow (MBS) studies, is usually inert but can lead to obstruction if retained, particularly in patients with diverticula or slow GI transit. We report a rare case of SBO in a 78-year-old man, potentially linked to retained barium from a recent MBS, highlighting the need to consider iatrogenic causes and the potential for conservative treatment. Case Description/Methods: A 78-year-old man with a history of CAD, gastroesophageal reflux disease, and hiatal hernia presented with progressive weakness and epigastric pain. Over 3 days, he experienced poor oral intake, debilitating weakness and 2 episodes of loose stools accompanied by burning epigastric pain. Vitals were stable. Physical examination was unremarkable except for epigastric tenderness, and lipase was normal. Initial symptomatic improvement was noted after GI cocktail. Abdominal X-ray revealed dilated small bowel loops (up to 5.1 cm) suggestive of SBO. A computed tomography (CT) abdomen/pelvis with contrast showed a dilated small bowel with a narrowed distal segment due to mural thickening and enhancement in the right abdomen concerning for evolving SBO. Hyperdense material was noted in the colon, likely residual from a prior MBS, suspected as retained barium contributing to obstruction, especially as dense material was seen near the ileocecal valve. A nasogastric tube was placed to low intermittent wall suction, with symptomatic improvement and eventual removal overnight. The patient was managed conservatively, with gradual return of bowel function. Follow-up imaging showed persistent but stable small bowel dilation, consistent with clinical improvement. Discussion: Small bowel obstruction (SBO) is a common surgical emergency, though rarely caused by retained contrast agents like barium sulfate. Typically inert, barium may contribute to obstruction in patients with altered motility or anatomy. In this case, hyperdense material near the ileocecal valve after a recent modified barium swallow suggested retained contrast worsening an evolving SBO. Though uncommon, iatrogenic causes should be considered, especially in high-risk patients. Conservative management was effective, underscoring the value of early recognition and tailored care.