A 74-year-old man with hypertension, old cerebral infarction, and alcoholic liver disease was referred to our hospital for intermittent abdominal pain around the navel. A physical examination revealed tension of the abdominal wall. His body temperature was 36.6 °C and weight and height were 71 kg and 166 cm, respectively. Laboratory results indicated the following: hemoglobin 10.7 g/dL, white blood cells 8,200/μL, C-reactive protein 0.89 mg/dL, and albumin 2.4 g/dL. Results from a kidney function test and clotting function examination were within the normal range. His history revealed that at the age of 71, he had been hospitalized for suspected infectious enteritis, as an abdominal computed tomography (CT) scan showed multiple wall thickness of the ileum. Because treatment with antibiotics proved successful, a close examination was not performed at that time. Though esophagogastroduodenoscopy results were unremarkable at this time, an abdominal CT scan showed the same observation previously (Fig. ). For further evaluation of the small bowel, capsule endoscopy was recommended.\nThe patient ingested a novel tag-less AgileTM patency capsule (Given Imaging Ltd., Yoqneam, Israel) for the evaluation of intestinal stenosis prior to capsule endoscopy. Eighteen hours after ingestion, he was referred to our hospital because of progressive abdominal distention and worsening terrible abdominal pain. The physical examination revealed marked tenderness. Laboratory tests indicated a white blood cell count of 25,000/μL. A CT scan showed the patency capsule trapped in his terminal ileum and intraperitoneal air (Fig. ). Emergent surgery was performed. During the surgical exploration, an ileum perforation was found proximal to the stricture of the terminal ileum in which the patency capsule was impacted (Fig. ). The sclerotic change of the ileum was recognized at 100-cm length from the ileocecal valve. An ileocolic resection, including the removal of the sclerotic ileum, was performed at this time (Fig. ). Pathological examination of the surgical specimen showed transmural inflammation and multiple ulcers with perforation of the small intestine, consistent with Crohn's disease. Following the operation, the condition of the patient's Crohn's disease has improved and is well controlled with drug therapy.
A 58-year-old Caucasian male with a reported 30 year history of CD presented to his gastroenterologist with intermittent diarrhea controlled by bismuth subsalicylate (Kaopectate). He denied any recent flares or pharmacologic management. A colonoscopy was negative for classical findings of CD and the patient next underwent WCE to document possible disease in the SB. On the evening of the procedure the patient reported poorly localized abdominal pain and copious non-bilious/non-bloody emesis. Over the next 48 hours he experienced progressive abdominal distention and presented to the Emergency Department. He denied the chronic use of NSAIDs or a history of prior abdominal operations.\nOn admission the patient was febrile, tachycardic and tachypneic. He also presented with severe hypotension requiring vasopressors. His physical exam was positive for icteric sclera, a distended abdomen with increased bowel sounds, and marked tenderness in the right lower quadrant. He had a WBC of 13.9 × 109/L (4.5-11.0 × 109/L) and platelet count of 79 × 109/L (150-450 × 109/L). His creatinine was 203.3 umol/L (58-111 umol/L) and total bilirubin was 171 umol/L (3-22 umol/L). A CT scan of the abdomen/pelvis revealed a capsule endoscope located near the terminal ileum along with diffusely thickened bowel wall, fat stranding in the right lower quadrant, hemorrhagic ascities and loculated free air (), reported as ischemic enteritis and SB perforation.\nAfter adequate resuscitation the patient was taken to the operating room where an ileocecectomy was performed, including removal of 160 cm of SB. The capsule endoscope found just proximal to the stricture. Given the patient’s hemodynamic instability the abdomen was initially closed with a 2 mm GORE-TEX (WL Gore & Associates Inc., Flagstaff, AZ) patch and loose suture. He required 12 subsequent operations for various complications and was discharged after 1 month with an ileostomy and colostomy. Pathology of the resected specimen showed an ileal stricture 15 cm proximal to the ileocecal valve, with associated necrotizing ileitis. A perforation was noted just proximal to the stricture where the capsule endoscope was found.