Barium Sulfate Deposition in the Gastrointestinal Tract: Review of the literature

Abstract

Background: Barium sulfate is utilized for imaging of the gastrointestinal tract and is usually not deposited within the wall of the intestine. It is thought that mucosal injury may allow barium sulfate to traverse the mucosa, and allow deposition to occur uncommonly. Most pathology textbooks describe the typical barium sulfate deposition pattern as small granular accumulation in macrophages, and do not describe the presence of larger rhomboid crystals. This review will summarize the clinical background, radiographic, gross, and microscopic features of barium sulfate deposition in the gastrointestinal tract. A review of the PubMed database was performed to identify all published cases of barium sulfate deposition in the gastrointestinal tract that have been confirmed by pathologic examination.

Conclusions: A review of the literature shows that the most common barium sulfate deposition pattern in the gastrointestinal tract is finely granular deposition (30 previously described cases), and less commonly large rhomboid crystals are seen (19 cases) with or without finely granular deposition. The fine granules are typically located in macrophages, while rhomboid crystals are usually extracellular. There are various methods to support that the foreign material is indeed barium sulfate, however, only a minority of studies perform ancillary testing. Scanning electron microscopy with energy dispersive X-ray spectroscopy (SEM/EDS) can be useful for definitive confirmation. This review emphasizes the importance of recognizing both patterns of barium sulfate deposition, and the histologic differential diagnosis.

Keywords: Barium sulfate; Granular and rhomboid deposition.

Fig. 1

Axial CT image of the pelvis showing multiple sigmoid colonic diverticula (orange arrow). Many of these diverticula demonstrate markedly hyperattenuating material filling them (orange arrowheads) which was proven to be barium sulfate after resection of the colon. There is a sigmoid anastomotic donut in trans-axial section (blue arrow) with hyperattenuating material within it as well. Evidence of classic gross barium material along the peritoneal surfaces was not seen in this case

Fig. 2

Histiocytes containing finely granular grey-brown material that was later confirmed to be barium sulfate. Background of granulation tissue with acute and chronic inflammation (H&E, 400 × magnification, 298 micron field width)

Fig. 3

Rhomboid crystals of barium sulfate in a background of acute inflammation (H&E, 400 × magnification, 298 micron field width)

Fig. 4

Radiograph of paraffin block showing opaque material in a case of barium sulfate deposition in the colon

Fig. 5

Scanning electron microscopy identifies the foreign material using backscattered electron imaging at 1000x (A) and detail of a fragmenting particle at 2500x (B). Note that the large particles may break down to tiny submicrometer particles often seen scattered in histiocytes by light microscopy. The chemical identification of the particles as Barium sulfate is confirmed by energy dispersive x-ray spectroscopy (EDS) (C), showing peaks for Barium and sulfur. High power view of rhomboid crystals in this case of barium sulfate deposition (D) (H&E, 400 × magnification, 298 micron field width)

Fig. 6

Irregularly shaped calcium oxalate crystals from a breast excision (H&E, 400 × magnification, 298 micron field width)

Fig. 7

Talc particles with plate-like appearance from a transbronchial biopsy related to inhalation (H&E)

Fig. 8

Crospovidone deposition showing darker purple on the outside and lighter purple on the inner aspects of the material (H&E, 400 × magnification, 298 micron field width)

Fig. 9

Microcrystalline cellulose with an elongated flakey appearance (H&E, 400 × magnification, 298 micron field width)