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 71-year-old man was admitted to the department of gastroenterology with diffuse abdominal pain. Through the previous 12 months, the patient had experienced episodes of vomiting and watery diarrhea of increasing intensity as well as weight loss. Both abdominal ultrasound and MRI had shown signs of terminal ileitis. Despite also having undergone a full colonoscopy and gastroscopy without confirmation of inflammatory bowel disease, the patient was suspected of having Crohn's disease. Six months prior to admission, the patient had swallowed a capsule endoscope, and the image feed was deemed normal.\nOn presentation, an abdominal CT-scan was performed (), showing mechanical small bowel obstruction with suspicion of metallic foreign body and perforation. Lab results showed C-reactive protein (CRP) of 204 mg/L.\nThe patient was taken to theater for a laparotomy. In the terminal ileum, approximately 5 cm from the ileocecal valve, a stenosis and a foreign body were found. Adhesions, chronic inflammation, and fibrinous cover characterized the area. A small perforation with localized fecal peritonitis was discovered near the ileocecal valve. A right hemicolectomy and distal ileectomy (60 cm) with an ileostomy were performed. On further inspection of resection, a capsule endoscope was found impacted in a stenosis (). The stenosis was histologically verified as Crohn's disease. The ileostomy was later reversed without complications.