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.
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.