Idiopathic inflammatory bowel disease associated with colonic tattooing with india ink preparation--case report and review of literature.

A case is reported in which the presence of a decorative tattoo resulted in pain and termination of an MRI study. The ferromagnetic nature of the tattoo and iron oxide tattoo pigments is demonstrated. The pathophysiology of tattoo/MRI interaction is discussed, as is an approach to the prevention and treatment of this complication. India Ink Tattooing in the Esophagus. Shaffer RT, et al. Gastrointest Endosc 1998;47:257-60 Background: Precise endoscopic measurement of esophageal landmarks is difficult and inaccurate because of the ability of the esophagus to lengthen and foreshorten. Methods: Nineteen patients enrolled to date in a study of Barrett's esophagus had an India ink tattoo placed at the most proximal level of the squamocolumnar junction and were examined endoscopically at 3, 9, 15, 24, and 36 months. Results: Eighteen of nineteen patients (94.7%) were judged to have a good to excellent tattoo persistence at 3 months. One of the 19 patients (5.3%) had poor tattoo persistence and was retattooed at the 3-month interval. Eventually, 15 of the 15 patients (100%) who remained in the study had a good or excellent tattoo persistence at 36 months. There were no complications related to India ink tattooing including chest pain, bleeding, or perforation. At follow-up endoscopy, no ulcers, inflammation, break in the mucosa, or pain were noted. Conclusion: India ink tattooing in the esophagus is safe and persistent and may be used as an effective method for longitudinal follow-up of lesions in the esophagus. Reproduced with permission from Mosby, Inc. India Ink Colonic Tattoo: Blots on the Record (editorial). Lightdale CJ. Gastrointest Endosc 1991;37:99-100 Endoscopic India ink tattooing of the colon was first described by Ponsky and King[1] in 1975 in this journal. The method has subsequently been advocated by experts as the best available means to mark the site of a colonic lesion pre-operatively.[2] In this issue, there are two new reports promoting colonoscopic India ink injection. Hyman and Waye[3] describe four-quadrant injection to facilitate operative localization, and Shatz and Thavorides[4] describe the use of two injections to “bracket” a polypectomy site for subsequent colonoscopic inspection. There were no complications in 40 patients receiving four quadrant injections or in 64 patients receiving two injections. Shatz and Thavorides[4] describe an inadvertent peritoneal injection in one patient without evident ill effect at laparotomy 5 days later. It came as a shock, therefore, to receive almost simultaneously two well-documented reports of complications following colonoscopic India ink injection in three patients, which also appear in this issue.[5.6] Reported untoward effects include fat necrosis, inflammatory pseudotumor, abscess, and focal peritonitis. Previous reports of complications were qualified: one occured after an injection into the stomach wall[7] and the other involved a canine model where the ink was mixed with alcohol.[8] The reasons for the complications described by Coman et al.[5] and Park et al.[6] in this issue are not clear. Both groups of investigators took pains to carefully autoclave the ink and used small injection volumes. Injection sites, of course, cannot be sterilized, but the problem may relate to the ink rather than the technique of injection. Even the earliest references to India ink indicate it is more than a suspension of carbon particles in water; to make India (also called China) ink, lampblack was bound by various gums and pastes.[9] British author Rudyard Kipling, who believed he wrote best only with the blackest ink, “would have kept an inkboy to grind me Indian ink."[10] Modern commercial India inks consist primarily of carbon particles and water, but also contain a wide variety of organic and inorganic compounds used as carriers, stabilizers, binders, and fungicides.[11,12] Does autoclaving these chemical soups result in additional substances capable of eliciting an inflammatory or allergic response? In their report, Hyman and Waye[3] emphasize that more experience is needed with these methods before the incidence of adverse effects can be defined. The need to mark an area of colon after removal of large or possibly malignant polyps is real. Of all methods tried so far, India ink injection seems the most promising. Hopefully, complications such as those reported in this issue will be infrequent. Continued cautious use of India ink in selected patients would not seem unreasonable. Perhaps, like Kipling, those performing colonoscopic tattoo should grind their own, or at least seek a more pure carbon suspension than commercial inks provide. Additional studies in controlled settings are certainly warranted, and the search for improved methods of marking a colonic polypectomy site should be intensified.