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.
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).\nThe 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 () 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 () 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.\nAt 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 (). 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.