Colonic obstruction caused by video capsule entrapment in a metal stent

Introduction

Video capsule endoscopy (VCE) has emerged as the method of choice for visualizing the small bowel mucosa (1,2). Beside the work-up of obscure gastrointestinal bleeding (OGIB) and in the evaluation of intestinal lesions related to non-steroidal anti-inflammatory drugs (NSAIDs) and celiac disease, VCE is particularly useful in the diagnosis and surveillance of Crohn’s disease (3-8). It is generally held that VCE is a safe method to examine the small bowel (9,10). Nonetheless, capsule retention is a feared complication with the potential to cause acute small bowel obstruction requiring emergency surgery (11).

We report an unusual case for the first time with capsule entrapment in a colonic metal stent necessitating surgical removal of the capsule in a patient with Crohn’s disease.

Case presentation

A 17-year-old man with total Crohn’s colitis verified with colonoscopy and histology underwent a small bowel follow-trough showing no signs of mucosal inflammation. The patient experienced frequent relapses and never reached remission. The small bowel was examined with VCE (PillCam^TMSB2, Medtronic, USA) in order to evaluate disease activity and extension for optimizing medical treatment. The VCE was incomplete but revealed no Crohn’s lesions in majority of the small intestine (Figure 1).

Figure 1 Incomplete capsule endoscopy showing normal mucosa in the small intestine.

Five months later, the patient presented in the emergency ward with severe abdominal pain and clinical signs of suspected intestinal obstruction. Abdominal plain X-ray and CT revealed a dilated bowel down to the sigmoid colon where a stricture was suspected. Concomitantly, it was found that the capsule was retained in the cecum (Figures 2,3). The patient was in a poor general condition and emergency surgery was considered to be too risky. Instead, the patient was treated with a self-expanding metal stent with the intention to bridge his care for surgery within two weeks. Stent placement in the sigmoid colon was successful and the intestinal obstruction was decompressed (Figure 4).

Figure 2 Plain abdominal X-ray showing colon dilatation from the cecum to the sigmoid colon and the retained capsule in the cecum.

Figure 3 Abdominal CT showing the retained capsule endoscope in the cecum.

Figure 4 Appearance of the stent immediately after stenting visualized by use of plain abdominal X-ray.

Two days later, the patient presented again with intestinal obstruction. An abdominal plain X-ray demonstrated that the colon was dilated from the cecum to the sigmoid colon where the capsule was observed to be trapped in the metal stent (Figure 5). The patient underwent an emergency Hartmann’s procedure and recovered uneventfully. The resected specimen showed severe inflammation and stricture in the sigmoid colon (Figure 6)

Figure 5 Plain abdominal X-ray showing colon dilatation from the cecum to the sigmoid colon where the capsule is trapped in the metal stent.

Figure 6 Resected specimen of sigmoid colon showing severe inflammation and stenosis.

Discussion

VCE is now an established method in the work-up of small bowel diseases (1,2). VCE is a safe technique and accumulating data from large studies indicate that the incidence of intestinal retention is less than 2%. Certain conditions, such as intestinal tumours and Crohn’s disease that limit passage in the small bowels may predispose capsule retention in the GI tract potentially causing bowel obstruction (9,10). The most common site of capsule retention is the small bowel, but other localizations, including oesophagus, stomach and airways have also been reported (12). The present case describes for the first time capsule entrapment in a colonic self-expandable metal stent in a patient with Crohns disease.

Clinical management of capsule retention includes medical, endoscopic or surgical treatment (1,10). Surgical interventions were most common in the in the early years of VCE use. However, this trend has changed and more recent studies have reported a more favourable clinical outcome using endoscopic techniques (13). In the present case, surgery was used to remove the retained capsule because of the benefit of concomitant removal of the obstructing lesion as well as the stent itself. Another advantage of surgical removal might be that it is possible to obtain pathological tissue for a diagnosis.

Although most cases of symptomatic capsule retention occur close to the time of capsule ingestion late cases of capsule retention-induced bowel obstruction has been reported. For example, in one case reported a 71-year-old man presented with acute intestinal obstruction and perforation six months after capsule ingestion (14). The majority of capsule retentions remain asymptomatic even for a longer time. According to the literature, the longest time for which a capsule has been left in situ is 12 years (15). Thus, if documentation of capsule expulsion is lacking or uncertain this must be taken into consideration when placing stents in the gastrointestinal tract.

The problem of capsule retention might be addressed by using patency capsule test. The patency capsule is made of self-dissolvable material and used before capsule endoscopy and retention of the patency capsule may constitute a contraindication to capsule endoscopy. Indeed, convincing studies have shown that use of patency capsule can minimize risk of capsule retention in patients with suspected small bowel strictures (16,17). However, the role of patency capsules in evaluating patency of GI stents especially those deployed in the colon is not known and remains to be studied. In this context, it should be mentioned that also patency test capsules can be retained and cause obstructive symptoms (18).

Based on our presented case, we conclude that patients with gastrointestinal stents should serve as a relative contraindication to VCE. The risk of intestinal obstruction and the potential need for surgical intervention should be clearly outlined for such patients if they have to undergo capsule endoscopy.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Informed Consent: Written informed consent was obtained from the patient for publication of this Case report and any accompanying images.

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