Retention of an endoscopic capsule.

Capsule endoscopy is a highly advanced, newer technology to look for small bowel diseases. But it has certain contraindications such as bowel narrowing, strictures that have to be ruled out on Barium studies or with computed tomography. We present a rare case of retention of endoscopic capsule even after ruling out stricture or bowel thickening on radiological imaging.

INTRODUCTION

Modern endoscopic techniques revolutionised the diagnosis and treatment of upper gastrointestinal (GI) tract and colon with the help of oesophago-gastro-duodenoscopy (OGDscopy) and colonoscopy, respectively. These aids work as the third eye for the treating doctors and give them the direct vision of the GI mucosa. But these diagnostic aids are not useful for small intestine disease evaluation. Newer techniques those expand the capabilities of diagnostic tools in diagnosing small intestinal diseases are double balloon enteroscopy, intra-operative enteroscopy and capsule endoscopy. Double balloon enteroscopy is able to evaluate up to jejunum and with more efforts up to ileum but it takes 45 minutes to 2 hours to perform[1] than routine endoscopy, which takes about 15-20 minutes.

Capsule endoscopy, known as wireless capsule endoscopy,[2] is now most commonly used for diagnosis of small intestinal diseases like obscure bleeding and other diseases like Crohn's disease, Celiac sprue, polyps, cancer, malabsorption, etc. Overall, in cases of what is known as occult bleeding (blood is microscopically present in the stool, but the stool looks normal), capsule endoscopy finds a potential source of bleeding in up to 68% of patients.[3] In cases of overt bleeding (blood is seen in the stool or the stool is black and tarry as a result of digested blood), the results are highly variable. If the bleed happened in the past, the yield may be as low as 6% and when there is active bleeding occurring at the time of the test, the yield is >90%.[4]

Capsule endoscopy has its limitations like it cannot take images of certain parts due to rapid transit, inability for intervention, low life of battery, time consuming, retention of capsule, intestinal obstruction and sometimes even the surgical procedures required for retained capsule. We present a case of retention of endoscopic capsule in small intestine.

CASE REPORT

A 46-year-old female presented with obscure GI bleeding with anaemia since 6-8 years. Patient complained of persistent weakness and repeated blood in stool. She was given six packed cell volume (PCV) transfusions in the past. Her stool occult blood was positive. Patient also underwent OGDscopy and colonoscopy repeatedly but no cause of bleeding was found. Her computed tomography (CT) scan of abdomen and pelvis was normal with no evidence of small bowel thickening or stricture.

Patient had past history of hypothyroidism, which was treated with medication and presented in euthyroid state on medication. She had primary infertility and underwent dilatation and curettage three times, besides diagnostic laparoscopy with separation of adhesions from fallopian tube. She had taken AKT for 6 months around 10 years back for genital kochs.

In view of obscure GI bleed, patient was advised capsule endoscopy. She took the ‘capsule’ but it could not be passed in stool even after 1 week. She was passing stools and flatus with no symptoms and signs of intestinal obstruction. She was given high fibre diet, laxatives and bowel preparations but capsule was still retained in bowel. X-ray abdomen and pelvis showed retained capsule on right side of vertebral column probable in small bowel [Figure 1a].

Figure 1

(a) Plain abdominal radiograph (b) CT scan showing retained endoscopic capsule in one of the distal ileum loops

Repeat colonoscopy was done to retrieve it but it was not visualised in terminal ileum. CT scan abdomen done after 3 weeks of retention showed 3.2 × 1.3 cm metallic foreign body in one of the distal ileum loops [Figure 1b].

Patient was posted for diagnostic laparoscopy, however, it was converted to mini-laparotomy due to inability to locate capsule endoscopy and due to adhesions. Adhesiolysis was done and capsule could be palpated in terminal ileum 2 feet proximal to ileo-cecal junction. Enterotomy was done distal to impaction of capsule and an intra-operative enteroscopy was done through this enterotomy both proximally and distally. It showed ulceration in one of the ileal loop along with thickening of the bowel wall and narrowing of the lumen. Capsule was removed and found stuck proximal to ulceration and narrowing [Figure 2a and b]. It was most probably due to the adhesions or ulceration in ileum that the capsule was retained. Distally multiple ulcerations were noted, hence resection of ulcerated and thickened ileum was done. Primary anastomosis was done to maintain the continuity. Post-operative course was uneventful. Histopathology confirmed it to be non-specific ulceration. Follow-up of 18 months has shown the patient to be symptom and disease-free with three consecutive stool examinations negative for presence of blood.

Figure 2

(a) Intra-operative endoscopic image (b) Cut open resected specimen of ileum showing ulceration & narrowing with retained endoscopic capsule

DISCUSSION

The causes of obscure GI bleed from small intestine can be multiple and difficult to identify such as vascular ectasia (most common), non-specific ulcers, Crohn's disease, large adenoma, carcinoma, haemangiomas, diverticuli (including Meckel's), Dieulafoy ulcer, tuberculous enterocolitis, etc.[5] Capsule endoscopy is most commonly used for diagnosis of small bowel obscure bleeding. It is safe and has good patient compliance and non-invasive. The role of video capsule endoscopy has expanded to inflammatory bowel disease, small-bowel neoplasms, malabsorption disorders, iatrogenic disease (NSAID strictures), radiation enteritis, clarification of previous imaging and chronic abdominal pain.[6]

Capsule endoscopy has been contraindicated in patients with known small-bowel obstruction, strictures, extensive Crohn's disease, swallowing disorders, pseudo obstruction, motility disorders, cardiac pacemakers and defibrillators. Relative contraindications include pregnancy, chronic NSAID use, extensive diverticular disease, gastroparesis and previous pelvic or abdominal surgeries.[7]

One of the most frequent complications of capsule endoscope is retention in small intestine. Capsule retention is defined as presence of endoscopic capsule in the digestive tract for a minimum of 2 weeks or more or when the capsule is retained indefinitely in the small bowel unless a targeted medical or surgical intervention is initiated.[8] The retained capsule may cause intestinal obstruction and may require emergency exploration. In the present case, CT scan ruled out any stricture or bowel thickening. Moreover, patient was asymptomatic with no symptoms or signs of intestinal obstruction. Hence trial with laxatives was given for natural passage of capsule. There have been cases where retained capsule was asymptomatic and was passed spontaneously after 2.5 years.[8] Retained capsule may be asymptomatic but it makes patient anxious and affects daily routine of the patient with frequent hospital visits. The retained capsule can be removed by double balloon enteroscope, laparoscopy or surgical procedure. In the present case, retained capsule required elective surgical exploration, which was done after 3 weeks of retention as patient was anxious but there were no signs of intestinal obstruction. Intra-operative enteroscopy helped in diagnosing ulcerations and narrowing responsible for occult bleed and retention of capsule. Primary resection anastomosis was done for stricturous lesion and ulcerations of ileum. This helped in treatment of pathology causing obscure GI bleed also.

The capsule, which is used to diagnose a disease, can itself cause problems like retention. Hence, imaging studies should be done before capsule endoscopy to rule out strictures or narrowing of the lumen. CT enteroclysis may be useful in diagnosing small bowel pathologies, however, current literature recommends capsule endoscopy as the third test of choice after upper and lower GI endiscopies in patients with obscure GI bleed.[9] However, sometimes even imaging studies like CT scan may not detect bowel thickening or adhesions as in present case.

CONCLUSION

In spite of ruling out any obstructive lesion in intestine on CT scan pre-procedure, still there are chances of retention of capsule. Hence a surgeon should be prepared to deal with, when such occasions arise. Intra-operative enteroscopy can be a useful tool to establish intra-luminal pathology like ulceration as a cause of retained endoscopic capsule.