Table of Contents Author Guidelines Submit a Manuscript
Case Reports in Gastrointestinal Medicine
Volume 2018, Article ID 9081742, 3 pages
https://doi.org/10.1155/2018/9081742
Case Report

Small Bowel Obstruction with Perforation Secondary to PillCam

1Department of Surgery, Western Hospital, Melbourne, VIC, Australia
2Department of Gastroenterology, St Vincent’s Hospital, Melbourne, VIC, Australia

Correspondence should be addressed to Toan Pham; ua.gro.hw@mahp.naot

Received 23 January 2018; Accepted 7 March 2018; Published 8 April 2018

Academic Editor: Yoshihiro Moriwaki

Copyright © 2018 Toan Pham et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

We present a case of a 63-year-old female who presented with small bowel obstruction and perforation secondary to a retained PillCam®. She initially presented with iron-deficiency anaemia (haemoglobin 44 g/L, ferritin 190 mcg/L). After unremarkable upper and lower gastrointestinal endoscopies and biopsies, she was referred for wireless capsule endoscopy (WCE). Four days afterwards she re-presented with small bowel obstruction and perforation related to the PillCam, which was confirmed on X-ray, on computed topography (CT), and at laparotomy.

1. Introduction

PillCam is a capsule endoscopy product used primarily to identify a site of gastrointestinal bleed in cases where both gastroscopy and colonoscopy have been negative. It is a camera capsule that is ingested and takes multiple digital photographs of the bowel during transit. In the vast majority of patients, the capsule is passed without difficulty. However, in some patients, such as those with extensive prior abdominal surgery, small bowel structuring, and radiation enteritis, the capsule can become stuck and potentially cause obstruction. We present a case of a 63-year-old woman who presented with small bowel obstruction and subsequent perforation secondary to a retained PillCam.

2. Case Report

A 63-year-old female presented with iron-deficiency anaemia (haemoglobin 44 g/L, ferritin 190 mcg/L). After unremarkable upper and lower gastrointestinal endoscopies and biopsies, she was referred for wireless capsule endoscopy (WCE).

The WCE study demonstrated an area of ulceration and stenosis in the distal jejunum. The capsule failed to pass the pathology within the duration of the capsule’s battery life (approximately 14 hours). Four days following ingestion, the patient presented with 48 hours of increasing generalised abdominal pain and nausea, but no vomiting. She had a mild fever of 37.8°C. On examination, the abdomen was distended and tympanic on percussion and generally tender, but there was no guarding. A plain abdominal X-ray (Figure 1) demonstrated multiple dilated loops of small bowel and air-fluid levels, suggestive of a small bowel obstruction. The wireless capsule can be seen in the left lower quadrant of the abdomen. A computed tomography (CT) scan of the abdomen (Figure 2) demonstrated the wireless capsule in the distal ileum, 15 cm proximal to the ileocaecal junction with evidence of perforation at this level. There was diffuse thickening of the terminal ileum distal to site of perforation.

Figure 1
Figure 2

At laparotomy, there was four-quadrant feculent peritonitis. The site of terminal ileum perforation was on the antimesenteric border, 15 cm from the ileocaecal valve, with the wireless capsule in situ (Figure 3). There was a 5 cm segment of markedly thickened ileum distal to the site of perforation. The resected specimen was histologically consistent with Crohn’s disease. The patient recovered well and was discharged from hospital five days after her operation.

Figure 3

3. Case Discussion

Capsule retention is an uncommon but well recognised complication of WCE occurring in approximately 1.4% of WCE studies. Causes of capsule retention included inflammatory strictures due to Crohn’s disease and NSAID enteropathy, as well as malignant lesions [1]. Crohn’s disease of the small bowel accounts for 35.3% of all cases of retention [1].

Small bowel obstruction and perforation are rarely seen with capsule retention [2]. However, abdominal adhesions from previous surgeries [2, 3], Crohn’s disease stricture [4], and necrotising ileitis [5] have been implicated.

A high index of suspicion as to the possible presence of small bowel stricturing prior to performing WCE is important in reducing the risk capsule retention. Certain conditions may predispose to obstruction and perforation—these include radiation enteritis, large small bowel tumor, extensive abdominal surgery, extensive small bowel or colon diverticulosis, previous GI perforation, and known fistulas. These are manufacturer-indicated contraindications to the use of the PillCam [6].

If small bowel stricturing is suspected, then preliminary investigations including a small bowel contrast series or MRI enterography can be undertaken. In patients with a high index of suspicion for bowel structuring or stenosis, a PillCam Patency Capsule may be given, which is a dissolvable capsule designed to emulate passage of PillCam [7].

Disclosure

Toan Pham is recipient of the 2018 RACS Foundation for Surgery Tour de Cure Cancer Research Scholarship.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

References

  1. Z. Liao, R. Gao, C. Xu, and Z. S. Li, “Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review,” Gastrointestinal Endoscopy, vol. 71, no. 2, pp. 280–286, 2010. View at Publisher · View at Google Scholar · View at Scopus
  2. P. González Carro, J. Picazo Yuste, S. Fernández Díez, F. Pérez Roldán, and O. Roncero Garciá-Escribano, “Intestinal perforation due to retained wireless capsule endoscope,” Endoscopy, vol. 37, no. 7, article 684, 2005. View at Publisher · View at Google Scholar · View at Scopus
  3. J. Picazo-Yeste, P. González-Carro, C. Moreno-Sanz, and J. Seoane-González, “Intestinal perforation secondary to impaction of a retained endoscopic capsule,” Cirugía Española, vol. 79, no. 5, pp. 316–318, 2006. View at Publisher · View at Google Scholar · View at Scopus
  4. S. Um, H. Poblete, and J. Zavotsky, “Small bowel perforation caused by an impacted endocapsule,” Endoscopy, vol. 40, no. 2, pp. E122–E123, 2008. View at Publisher · View at Google Scholar · View at Scopus
  5. D. A. Parikh, J. A. Parikh, G. C. Albers, and C. F. Chandler, “Acute small bowel perforation after wireless capsule endoscopy in a patient with Crohn's disease: A case report,” Cases Journal, vol. 2, no. 7, article no. 7607, 2009. View at Publisher · View at Google Scholar · View at Scopus
  6. M. Borland, “User's manual for elegant Program Version 12.4, Manual Version 1,” Tech. Rep. LS-231, 1993. View at Publisher · View at Google Scholar
  7. J. Durand, “Given Imaging: une Plateforme Technologique Unique pour l’intégration de la gamme de capsules Pillcam® Pillcam® SB ⇒ Capsule de reference pour I’intestin grêle Pillcam® ESO ⇒ Capsule bi-imageurs pour I’œsophage Patency AGILE ⇒ Capsule de calibrage du tractus digestif,” Acta Endoscopica, vol. 36, no. 2, pp. N1–N2, 2006. View at Publisher · View at Google Scholar