Acute Symptomatic Small Bowel Obstruction Due to Capsule Impaction

Abstract

Capsule impaction is a well recognized complication of small bowel capsule endoscopy, with an incidence ranging from 0.75 to 21%, depending on the indication. To date, there have been no reported cases of capsule impaction causing acute symptomatic small bowel obstruction. We now present 3 cases of acute small bowel obstruction due to capsule impaction. Case 1: A 71 year-old woman had iron deficiency anemia in the setting of negative upper endoscopy, colonoscopy, small bowel follow-through, enteroclysis and push enteroscopy. She developed severe abdominal pain, vomiting and leukocytosis 16 hours after capsule ingestion. Emergent surgery was performed to remove the capsule which was impacted at a previously undiagnosed ileal Crohn's stricture leading to perforation. Case 2: A 64 year-old woman with Gardner's syndrome and a history of colectomy and subsequent episodes of small bowel obstruction underwent capsule endoscopy in order to define the site of obstruction. She experienced drastically increased abdominal pain 24 hours after capsule ingestion, and emergent enteroscopy was required to retrieve the capsule which had become impacted at a previously undiagnosed annular cancer in the distal duodenum, ultimately treated with surgical resection. Case 3: An 85 year-old man with recurrent small bowel obstruction due to radiation enteritis underwent capsule endoscopy in an attempt to localize the site of obstruction in preparation for surgical intervention. He returned with severe abdominal pain and emesis 3 days later. At surgery, the capsule was found to be impacted at a radiation stricture in the ileum and was removed with resection of the surrounding small bowel. These 3 cases show that acute symptomatic obstruction and even perforation can occur as a result of capsule impaction, especially in patients at high risk for obstruction because of their past history. We propose that the possibility of acute symptomatic small bowel obstruction be included in the informed consent for capsule endoscopy. Patients should be warned that emergent surgery may be needed to remove an impacted capsule; this may have implications for patients living far away from the medical center who plan on traveling home immediately after capsule endoscopy.