2537 Case of an Incidental Small Bowel Adenocarcinoma Upon Surgical Evacuation of a Retained Video Capsule Endoscopy in a Patient With Crohn's Disease

Abstract

INTRODUCTION: Here we report the case of a patient with Crohn's disease in whom a video capsule got lodged in a small bowel stricture and upon surgical evacuation of the capsule small bowel adenocarcinoma was incidentally found. This case emphasizes that it is important to consider small bowel adenocarcinoma in Crohn's disease patients with obstructive signs. This case also demonstrates the management of a retained capsule in Crohn's patients. CASE DESCRIPTION/METHODS: A 28 year old male with history of Crohn's disease presented for an evaluation of bright red blood per rectum and severe anemia. Initial evaluation with a colonoscopy and EGD revealed no source of bleeding and thus a video capsule was placed. Two days after placement of the capsule the patient began having severe abdominal pain. A KUB revealed that the capsule was still at the ileocecal valve, indicating that it was possibly stuck in a stricture. The patient was started on IV methylprednisolone in order to reduce inflammation to allow for passage of the capsule. Upon further evaluation, surgical intervention was necessary to remove the capsule. In the operating room the surgeons visualized a tumor in the jejunum arising from a Crohn's stricture. Despite multiple inspections of the resected small bowel the capsule could not be located. An intraoperative x-ray revealed the capsule to be in the splenic flexure of the colon indicating that the capsule passed through the stricture prior to resection. The final pathology revealed metastatic poorly differentiated adenocarcinoma. DISCUSSION: Small bowel adenocarcinoma is a recognized however overlooked complication of Crohn's disease. In patients with non-concerning colonoscopies with signs of obstruction (such as a retained capsule) and severe anemia, small bowel adenocarcinoma should be strongly considered. Capsule retention is often diagnosed via abdominal x-ray such as in our case. A retained capsule often remains asymptomatic however carries the risk of perforation, secondary obstruction, or ulceration. Double-balloon enteroscopy is considered the primary method for capsule retrieval however surgical exploration is often done. The concern for the capsule being lodged in a stricture in our patient made surgery the best option. We did first attempt IV methylprednisolone and within the five day interval prior to surgery the capsule had passed into the colon. In Crohn's disease patients, immunosuppressive medications such as steroids and infliximab have been shown to facilitate capsule passage.