A Newborn with Barium Sulphate Aspiration Following Barium Contrast Study for Esophageal Atresia: A Case Report

We present a case of a newborn with barium sulphate aspiration following barium contrast study for investigation of suspected esophageal atresia. In the literature little has been reported on barium aspiration in childhood and there is no established protocol for treatment. We describe an operative method for treating baritosis - segmental to subsegmental bronchial excision, used in children with bronchiectasis. Edmond Rangelov, Nadezhda Tolekova, et al., A Newborn with Barium Sulphate Aspiration Following Barium Contrast Study for Esophageal Atresia: A Case Report. Biomed J Sci & Tech Res 37(4)-2021. BJSTR. MS.ID.006033.


Introduction
In the literature little has been reported on barium aspiration in children and there is no established protocol for treatment.
We present a case of a newborn with barium sulphate aspiration following barium contrast study for investigation of suspected esophageal atresia. The treating modality includes an operative method for treating baritosis -segmental to subsegmental bronchial excision, routinely used in children with bronchiectasis.
The case illustrates the importance of an accurate assessment, rapid diagnosis and prompt primary surgical repair. It is an example of a good long-term outcome due to the successful collaboration in a multidisciplinary team.     There are many reports of cases where no clinical symptoms, either acute or chronic, were found -16 cases described by Wilson, et al. [2]; 19 cases (including 3 children) -by Shook, et al. [3]; over 200 human bronchograms -by Teixeria, et al. [4]. On the contrary, some authors describe acute respiratory distress, pneumonitis and even deaths [5][6][7]. Others report mortality rate associated with massive barium aspiration approximately 30% which may reach up to 50% depending on the initial patient's condition [8]. These different consequences can be explained by the influence of many factors like age, pre-existing clinical state, the concentration of the barium used [7,9], the volume aspirated, and concomitant aspiration of gastric contents [10]. The distribution pattern of the barium within the tracheobronchial tree is determined by the patient's posture at the time of the study and clearance mechanisms such as cough, mucociliary escalator clearance, and cellular ingestion.

Case Report
In our case we have assumed that the immaturity of the neonate's lungs combined with barium aspiration and the trauma from the thoracotomy performed for the concomitant esophageal atresia led to failure in weaning of ventilation and persistent pneumonitis. Some authors conclude that bronchoalveolar lavage is mandatory after barium aspiration [7]. On the contrary, others deny the lavage, because it may disseminate the barium further within the bronchoalveolar system [11]. We have tried to use fiberoptic bronchoscopy and bronchoalveolar lavage to reduce the amount of barium depositions with unsatisfactory result.
In this case we propose an operative technique of treatment for baritosis -subsegmental bronchial resection, described in 1988 by Isakov as a method of surgical treatment for bronchiectasis in children [1]. The advantage of this method is that the residual pulmonary parenchyma can still be pneumatized via interalveolar paths. This also preserves the blood supply and avoids formation of residual cavity and chest deformity. Similar results can be seen in an experimental study in dogs -extirpation of bronchi, described by Zhonghua Wai Ke Za Zhi in 1996. In the control group of this study (with segmental resection) heavy destruction, consolidation and emphysema were observed in the adjacent lung tissues, while in the experimental group the residual lung tissues only had little wound reaction and no atelectasis.
[12] Our case report shows that the barium will remain in the lung for a long period of time but is relatively inert.

Conclusion
There are many factors influencing the variety of consequences after barium sulphate aspiration. We believe that in cases without significant respiratory disturbances only supportive care is indicated. Patients with mild symptoms may benefit of therapeutic bronchoalveolar lavage. In those with respiratory distress and prolonged necessity of mechanical ventilation segmental to subsegmental bronchial extirpation should be considered.