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 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.