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.
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.