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Japanese Journal of Comprehensive Rehabilitation Science (2020)

Original Article

Colonic retention of barium with and without use of laxatives aftervideofluoroscopic examination of swallowing
Takashi Tanaka, MD, DMSc,1,2 Hitoshi Kagaya, MD, DMSc,1 Naoya Yamanouchi, MD,3Takatoshi Iida, DDS, PhD,4 Seiko Shibata, MD, DMSc,1 Eiichi Saitoh, MD, DMSc1
Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
Hyogo Prefectural Rehabilitation Hospital at Nishi-Harima, Tatsuno, Hyogo, Japan3
Department of Rehabilitation, Saga-Ken Medical Centre Koseikan, Saga, Saga, Japan
4
Department of Critical Care Medicine and Dentistry, Division of Medically Compromised Geriatric Dentistry
Graduate School of Dentistry, Kanagawa Dental University, Yokosuka, Kanagawa, Japan
12ABSTRACT
Tanaka T, Kagaya H, Yamanouchi N, Iida T, Shibata S,Saitoh E. Colonic retention of barium with and without
use of laxatives after videofluoroscopic examinationof swallowing. Jpn J Compr Rehabil Sci 2020; 11:
73‐77.
Objective: Barium is generally used as the contrast
medium in videofluoroscopic examination of swallowing(VF) to evaluate swallowing function. However, noconsensus has been reached on the use of laxatives
following VF. The objectives of the present study were toassess the status of colonic retention of barium after VF
and to examine the usefulness of laxatives.
Methods: In study 1, 88 patients who underwent VF andabdominal radiography 3 days after VF were studied.
Barium dose, site of retention, number of sites ofretention, and gastrointestinal symptoms were evaluated.
In study 2, 51 patients who received ≥10 g of barium atVF and laxatives were compared with 63 patients whoreceived ≥10 g of barium without laxatives in study 1.
Results: In study 1, barium retention was observed in
60 patients. The barium retention and number of sites ofretention were significantly greater in patients who
received ≥10 g of barium (p < 0.001). In study 2, barium
at the most oral side moved more distally toward theanal side in patients who received laxatives (p = 0.043)
and the number of sites of barium retention was reduced(p = 0.017).
Conclusions: Barium retention is common when >10
g is used in VF. Administration of laxatives promotes

barium excretion.
Key words: dysphagia, videofluoroscopic examinationof swallowing, barium, laxative

Correspondence: Hitoshi Kagaya, MD, DMSc
Department of Rehabilitation Medicine I, School ofMedicine, Fujita Health University, 1‐98 Dengakugakubo,
Kutsukake, Toyoake, Aichi 470‐1192, Japan.
E-mail: hkagaya2@fujita-hu.ac.jp
Accepted: March 16, 2020.
Conflict of Interest: The authors declare that there are noconflicts of interest.

In our hospital, VF is conducted using a barium
suspension at a concentration of 50% w/v; for example,
the barium content of 10 mL of liquid is 5 g. This study
was approved by the relevant institutional ethicalcommittee.

©Kaifukuki Rehabilitation Ward Association 2020
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Introduction
Videofluoroscopic examination of swallowing (VF)is the gold standard for the assessment of swallowing
function [1‐3], and barium is generally used as thecontrast medium. Regarding the use of laxatives ingastrointestinal tract imaging studies, there are many
reports on administration before examination [4,5], but
few detailed reports on administration after examination.
Massive colonic retention of barium has been reported
in the elderly after examination, and retention is
improved by lactulose administration [6]. Difficulties in
defecation and constipation have been reported after
gastrointestinal tract imaging studies, as well as
subsequent occurrences of gastrointestinal tract
perforation [7], peritonitis [8], and bowel occlusion [9].
Although minimizing colonic barium retention isclearly desirable, no consensus has been reached on
the use of laxatives following VF. To the best of ourknowledge, barium retention after VF has not been
investigated. The objectives of the present study werethus to elucidate the status of colonic retention ofbarium after VF and to examine the usefulness oflaxatives.
Methods

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Tanaka T et al.: Colonic retention of barium after VF

Study 1: Status of colonic retention of barium
Patients hospitalized in our institution between
September and December 2007 who were suspected ofhaving dysphagia and underwent VF and then abdominal
radiography 3 days later were included in this study.
Written informed consent was obtained from the subjects
or their families. Abdominal radiography was conductedin a supine position, and images up to the level of the
pubic bone were acquired. Abdominal radiographs wereassessed for barium retention with the greatest diameterof 10 mm or above at the most oral side and the most analside in five colorectal sites: ascending colon, transversecolon, descending colon, sigmoid colon, and rectum(Figure 1). The dose of barium used during VF, presenceor absence of barium retention, and number of sites ofbarium retention spanning the above-mentioned sites
were assessed. In addition, abdominal symptoms
including abdominal pain, vomiting, and diarrhea
observed between the time of VF and radiography, as
well as the status of defecation, were recorded. Diarrhea
was defined as a defecation frequency of three times ormore per day. The relationship between defecation status
and barium dose was also analyzed.

formed the laxative group. Written informed consent
was obtained from all subjects. Patients who wereadministered a laxative for other reasons were excluded.
Patients in this group were administered 15 drops ofsodium picosulfate hydrate solution (LaxoberonTM;Teijin Pharma Ltd.) orally or via a feeding tube before
bedtime on the day of VF. Abdominal radiographs wereassessed for barium retention with the greatest diameterof 10 mm or above at the most oral side and the mostanal side in five colorectal sites: ascending colon,transverse colon, descending colon, sigmoid colon, andrectum. The number of sites of barium retention
spanning the above-mentioned sites was assessed.
Subjects in study 1 who received 10 g or more ofbarium were designated the non-laxative group. The
site of retention and status of retention at the most analside and the most oral side were compared. The
number of sites of retention was also compared
between the laxative and non-laxative groups. In
addition, abdominal symptoms including abdominal
pain, vomiting, and diarrhea observed between thetime of VF and radiography, as well as the status ofdefecation, were recorded.

Study 2: Usefulness of laxative administration
Among patients who underwent VF for suspected
dysphagia during hospitalization in our institution
between April 2010 and July 2011, those who received
10 g or more of barium, were administered a laxative,and underwent abdominal radiography 3 days after VF

Statistical analysis
Numerical data are expressed as mean ± standard
deviation. The relation between barium dose andpresence or absence of barium retention on abdominal
radiograph, the relation between barium dose andstatus of defecation, and gender were analyzed using
the Chi-square test. The numbers and site of barium
retention were analyzed using the Mann-Whitney U
test. In study 2, the mean ages and barium dose of thelaxative and non-laxative groups were compared using
Welch’s t-test. Statistical analyses were performed
using SPSS version 19 (IBM Japan, Tokyo, Japan).
p-values less than 0.05 were considered to indicate
statistically significant differences.
Results

Figure 1. Abdominal radiograph taken 3days after videofluoroscopic examinationof swallowing.
Retention of barium continuously fromthe descending colon to the rectum isobserved.

Study 1
Eighty-eight subjects (68 males and 20 females, aged
62±20 years) participated in this study. The primarydiseases were cerebrovascular disease in 39 patients,
head trauma in 5 patients, other cerebral diseases in 6patients, neuromuscular disease in 12 patients, respiratory
disease in 4 patients, oropharyngeal tumor in 7 patients,and other conditions in 15 patients. The dose of barium
administered during VF was 24.5±16.6 g. Barium
retention was observed on abdominal radiographs afterVF in 60 of 88 (68%) patients. Barium retention extending
from the ascending colon to the rectum was observed in19 patients, and the lowest barium dose used in thesepatients was 12.5 g (Figure 2).
In the barium dose <10 g group, no retention wasobserved in 15 of 25 patients (60%). Barium retention
was significantly more common in the barium dose ≥10Jpn J Compr Rehabil Sci Vol 11, 2020

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Tanaka T et al.: Colonic retention of barium after VF

Figure 2. Barium dose and retention site in study 1.
Barium retention was observed on abdominal radiographs aftervideofluoroscopic examination of swallowing in 60 of 88 patients.
Barium retention extending from the ascending colon to the rectum
was found in 19 patients, and the smallest barium dose used in thesepatients was 12.5 g.
g group than in the <10 g group (p < 0.001) (Table 1).
The number of sites of retention was also significantly
greater in the barium dose ≥10 g group (p < 0.001)(Table 2). Ten patients had no defecation during the 3days between VF and abdominal radiography. Threepatients experienced abdominal pain, and one patientreported vomiting after VF, all of whom had nodefecation. In the three patients with abdominal pain,
the symptom was resolved after defecation. In thevomiting case, vomiting occurred on day two after VF;
defecation occurred later on the same day, and there wasno recurrence of vomiting. None of the patients
experienced diarrhea.

patients, neuromuscular disease in 1 patient, respiratory
disease in 6 patients, oropharyngeal tumor in 3 patients,and other conditions in 14 patients. The dose of bariumin the laxative group was 28.8 ± 10.2 g. Barium retention
was observed on abdominal radiographs after VF in 35patients. Barium retention extending from the ascending
colon to the rectum was found in 12 patients, and thesmallest barium dose used in these patients was 15.9 g(Figure 3). Three patients reported no defecation for 3days. Eventually, all patients had defecation, and thelatest defecation was 6 days after VF.
Among the 88 patients in study 1, 63 patients (53males and 10 females, aged 65±18 years) who received
10 g or more of barium were designated the non-laxativegroup. The primary diseases were cerebrovasculardisease in 29 patients, head trauma in 3 patients,neuromuscular disease in 10 patients, respiratory diseasein 3 patients, oropharyngeal tumor in 7 patients, and otherconditions in 11 patients. The dose of barium in the non-Study 2
Fifty-one patients (37 males and 14 females, aged
66±14 years) were administered a laxative. The primarydiseases were cerebrovascular disease in 23 patients,
head trauma in 1 patient, other cerebral diseases in 3

Table 1. Barium dose and status of barium retention.
Barium dose

Absence of retention

Presence of retention

Total≥10 g<10 g

131550106325Total

286088(p<0.001; Chi-squared test)
Table 2. Barium dose and number of sites of barium retention.
Barium dose≥10 g<10 g

Number of sites of barium retention
01234513156544131

80190Total6325(p<0.001; Mann-Whitney U test)
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Tanaka T et al.: Colonic retention of barium after VF

laxative group was 32.5±12.3 g. No significant differencesin gender, age, and the dose of barium were observed
between the laxative and non-laxative groups. The twogroups did not differ significantly in barium retention
sites at the anal side (p=0.120), but did differ significantly
in sites at the oral side (p=0.043); barium was also shown
to move more distally to the anal side in the laxative
group (Table 3). The number of sites of barium retention

was significantly lower in the laxative group (p = 0.017)(Table 4). Regarding gastrointestinal complications,
three patients in the laxative group reported abdominal
pain and three patients reported diarrhea. In all threepatients with abdominal pain, the symptom improved
after defecation. In the three patients with diarrhea,defecation occurred 4‐6 times on the day after laxative
administration and improved to 2‐3 times 1 day later,

Figure 3. Barium dose administered and retention site in the laxative
group in study 2.
Barium retention was observed on abdominal radiographs aftervideofluoroscopic examination of swallowing in 35 patients. Barium
retention extending from the ascending colon to the rectum was foundin 12 patients, and the smallest barium dose used in these patients was15.9 g.
Table 3. Laxative use and sites of retention.
Oral side
LaxativeuseNo
retention

RectumSigmoidcolon

Descending
colon

Transverse
colon

Ascending
colon

Total

Yes
No

16139610387615305163(p=0.043; Mann-Whitney U test)
Anal side
LaxativeuseNo
retention

RectumSigmoidcolon

Descending
colon

Transverse
colon

Ascending
colon

Total

Yes
No

16
132936182402

305163(p=0.120; Mann-Whitney U test)
Table 4. Laxative use and extent of retention.
Laxative useYesNo

Extent of retention
0123451613136255121011516Total
5163(p=0.017; Mann-Whitney U test)
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Tanaka T et al.: Colonic retention of barium after VFwith no diarrhea thereafter.
Discussion
Colonic retention of barium was observed after VF in
68% of all subjects in study 1, and retention wasdistributed extensively from the ascending colon to therectum in 22% of patients; all of whom received barium
doses of 10 g or more. The finding that barium retention
was significantly more frequent in patients administered
10 g or more indicates that, even in VF, which uses asmaller dose of barium compared with gastrointestinal
imaging, retention is common when the dose exceeds acertain level. However, complications were limited to afew cases of mild symptoms including transient
abdominal pain and nausea, suggesting a low risk ofserious gastrointestinal complications.
Study 2 revealed that when 10 g or more of barium
was used during VF, laxatives facilitated the excretionof barium toward the anal side and out of the body.
According to a report on barium excretion after agastrointestinal imaging study, barium was detected in
the feces of 44% of subjects on the same day as
imaging and 85% of subjects on the next day, indicating
excretion within 2 days in most subjects [10]. Other
studies have reported barium excretion as soon as 30
min and as late as 5 days, with the majority of excretionoccurring within 20 to 40 h after gastrointestinal
imaging study [11]. No serious complications such as
dehydration or persistent diarrhea occurred in thisstudy. Therefore, we verified that laxatives enhancebarium excretion in a safe manner.
Although laxatives are not generally administeredafter VF, barium retained in the gastrointestinal tract
may pose a risk of gastrointestinal perforation,
peritonitis, and bowel obstruction [7‐9]. Hence, theuse of laxatives is recommended for patients with nocontraindications who receive a barium dose of 10 g orabove. When barium stagnation occurs even after
laxative use, dietary content and water intake before
and after the imaging study, as well as lifestyle factors
including defecation patterns, may be contributing
factors.
It remains unclear whether further administration oflaxative should be considered in patients with barium
retention even after laxative use. Abdominal radiography
can be used to effectively assess barium retention insuch cases. VF was conducted in patients with suspected

dysphagia, and oral administration of laxatives may
cause aspiration. Therefore, the administration route of
the laxative should be carefully determined on the basisof VF results. Moreover, as the patients in the laxative
group and the non-laxative group in study 2 were notcompared in the same period, the results should beinterpreted carefully because the treatment for primarydiseases may be different.
In conclusion, the present study demonstrated thatbarium retention is common when used at a dose of 10g or above during VF and that laxatives are effective
for promoting barium excretion.

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