A 55-year-old Italian woman was referred to our division when she complained of severe cramping abdominal pain and vomiting approximately 36 hours after ingestion of a capsule endoscope.\nOver the preceding years, she had undergone an extensive workup for recurrent postprandial cramping pain and iron deficiency anemia, including an abdominal ultrasound, upper endoscopy, colonoscopy and small bowel follow-through radiograph, all of which showed negative results. The physical examination on her admission revealed a mildly distended abdomen with increased bowel sounds. Laboratory tests showed normal results except for a red blood cell count of 3.15 million/mL (normal: 4.0 million to 5.4 million/mL) and hemoglobin of 9.8g/dL (normal: 12g/dL to 16g/dL). A plain abdominal film demonstrated a retained capsule in her small bowel without clear-cut signs of bowel obstruction. The endoscopist obtained images from the CE revealing a suspected neoplastic-like stricture in her mid-small bowel (Figure ). Over the following 24 hours, our patient experienced progressive abdominal distention, worsening abdominal pain and vomiting, as well as development of leukocytosis. A computed tomography (CT) scan was then performed showing that the capsule was trapped in her proximal ileum, and that there was extensive small bowel dilatation along with free peritoneal air (Figure ). Our patient underwent an urgent laparotomy during which an ileal perforation was found (Figure ) proximal to a neoplastic-like stricture in the mid-ileum. An ileal resection with end-to-end anastomosis was therefore performed. Her postoperative course was uneventful, and our patient was discharged seven days later. Pathology confirmed the diagnosis of a well-differentiated ileal adenocarcinoma penetrating the entire wall and the mesentery, without lymph node invasion. Eleven months later, our patient had been treated with chemotherapy and was feeling generally well.
A 50-year-old man with gradually worsening anemia and suspected small bowel bleeding was referred to our hospital to undergo CE because esophagogastroduodenoscopy and total colonoscopy did not reveal the source of the gastrointestinal bleeding. His oral medications included several psychoactive drugs and iron preparations but not nonsteroidal anti-inflammatory drugs. He had no history of abdominal surgery. We did not perform patency examination before CE because we assessed low possibility of severe stenosis and inflammatory bowel disease based upon his clinical history and abdominal X-ray examination. CE (PillCam SB2 system, Given Imaging, Yokneam, Israel) demonstrated several ulcers at the small intestine, but the capsule did not reach the cecum during the recording time (stomach transit time: 220 minutes). These results were sent to his primary care doctor. Five months after the CE examination, he was referred again for the recurrence of anemia. Abdominal X-ray examination revealed that the capsule was retained at the pelvic cavity (). Follow-up abdominal X-ray examination after 7 days demonstrated that the capsule remained in exactly the same part but was rotatable (). Computed tomography (CT) showed that the capsule seemed to be floating in the small intestinal lumen with dilatation and fluid collection proximal to the capsule (). Additionally, the CT coronal view indicated findings suspicious for stenosis distal to the capsule (). The patient had had regular bowel movements and no abdominal complaints for the past 5 months. He could not confirm that the capsule was egested because he failed to monitor his stools. After proper informed consent was obtained, we retrieved the capsule by laparoscopy-assisted surgery. The patient declined endoscopic approach and treatments. Laparoscopic instruments were placed through 3 trocars. The CE was laparoscopically detected approximately 50 cm from the end of the ileum. After fluoroscopic confirmation, the part of the ileum with the capsule was moved outside the abdominal cavity, and we made the following observations around the area of retention: the fat-wrapping sign and a caliber change were observed distal to the capsule, with reddened serosa proximal to the capsule. The capsule could not pass through this stricture (). The small intestine was extensively evaluated, and no other abnormalities were found. We resected approximately 30 cm of ileum and performed a functional end-to-end anastomosis. An ulcer scar with stricture was macroscopically observed, and a wide ulcer was observed at the proximal side of the lesion (). On histopathological examination, the lesions were determined to be a nonspecific ulcer (Ul III) with fibrosis, formation of lymphoid follicles, and infiltration of monocytes and neutrophils to the subserosa, without evidence of malignancy, inflammatory bowel disease, or tuberculosis (). The patient's postoperative course was uneventful, and he was discharged on the postoperative day 8. There was no evidence of progression of anemia at a follow-up visit conducted 7 months after surgery.