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Wireless Capsule Endoscopy Fragmentation in a Patient With Crohn's Disease

2011; Elsevier BV; Volume: 9; Issue: 11 Linguagem: Inglês

10.1016/j.cgh.2011.04.018

1542-7714

Márcia Henriques de Magalhães Costa, André da Luz Moreira, Cyrla Zaltman,

Gastrointestinal Tumor Research and Treatment

A 53-year-old woman presented with recurrent episodes of abdominal pain and anemia with nonconclusive endoscopic, radiological, and scintigraphic evaluations. She received steroids, mesalazine, metronidazole, and azathioprine for a suspected diagnosis of Crohn's disease (CD), without clinical improvement. After 8 years of evolution, a wireless capsule endoscopy (WCE) detected ileal ulcers and inflammatory stenosis compatible with CD (Figure A). The capsule did not pass through the ileocecal valve, but an abdominal X-ray was not performed as the patient discontinued follow-up. After 3 years, she presented an intestinal subocclusion and an abdominal X-ray revealed capsule retention (CR) on the right lower abdominal quadrant (Figure B), confirmed by computed tomography scan (Figure C). Elective laparoscopic surgery intended for stenosis correction and capsule withdrawal was performed, revealing extensive small bowel disease and adherences. The capsule was not detected, and adherences dissolution was performed. After 4 months, a new abdominal X-ray revealed 3 metallic images in different intestinal segments, suggesting capsule fragmentation (CF) (Figure D). A computed tomography scan confirmed this finding and detected the presence of multiple small bowel strictures (SBS). Steroids and infliximab were not effective in helping the capsule liberation. Due to clinical deterioration, an open abdominal surgery was carried out, resecting 70 cm of stenotic small bowel with the removal of 4 capsule fragments (Figure E and F). WCE allows the direct examination of the entire small bowel. Its major reported complication is CR, with or without obstruction. Importantly, CD patients are considered to be at higher risk for CR.1Cheifetz A.S. Kornbluth A.A. Legnani P. et al.The risk of retention of the capsule endoscope in patients with known or suspected Crohn's disease.Am J Gastroenterol. 2006; 101: 2218-2222Crossref PubMed Scopus (303) Google Scholar The use of a patency capsule can reduce the retention rate, but it was not available in Brazil at that time. The WCE has its role in the evaluation of unrecognized or uncertain SBS by other image tests,1Cheifetz A.S. Kornbluth A.A. Legnani P. et al.The risk of retention of the capsule endoscope in patients with known or suspected Crohn's disease.Am J Gastroenterol. 2006; 101: 2218-2222Crossref PubMed Scopus (303) Google Scholar and it is still debatable whether known SBS are a contraindication to WCE.2Yang X.Y. Chen C.X. Zhang B.L. et al.Diagnostic effect of capsule endoscopy in 31 cases of subacute small bowel obstruction.World J Gastroenterol. 2009; 15: 2401-2405Crossref PubMed Scopus (24) Google Scholar If the device is not eliminated after 2 weeks of the procedure, an abdominal X-ray should be performed to confirm CR. Endoscopic or surgical removal of a retained capsule is indicated in the presence of clinical complaints, but there is no recommendation regarding time to remove the capsule in asymptomatic patients.3Cave D. Legnani P. de Franchis R. et al.ICCE consensus for capsule retention.Endoscopy. 2005; 37: 1065-1067Crossref PubMed Scopus (306) Google Scholar, 4Eliakim R. Video capsule endoscopy of the small bowel.Curr Opin Gastroenterol. 2008; 24: 159-163Crossref PubMed Scopus (51) Google Scholar Published reports of CF are rare, and this called our attention when the capsule was described as being designed as a "miniature missile,"5Halpern M. Jacob H. Atlas of capsule endoscopy.1st edition. Given Imaging, Inc, Ltd, Yoqneam, Israel2002Google Scholar which should be resistant to any damage. We do not believe that the slight surgical manipulation could have possibly caused CF. This case illustrates a new possible complication of WCE that can occur after longstanding CR or a minor trauma, making it necessary to rethink which is the best moment to remove the retained capsule. The authors thank Tiago Nunes (Hospital Clinic/IDIBAPS, Barcelona) and André Luiz Moreira Torres (Gastroenterology Unit, HUCFF, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil) for their substantial contributions to this report.