Asymptomatic Tracheal Aspiration of Capsule Endoscopy in a Patient Without Dysphagia.

Abstract

CASE REPORT An 84-year-old man with a significant history of hypertension, coronary artery disease, congestive heart failure, and osteoarthritis was referred for an evaluation of iron deficiency anemia. Previous upper endoscopy and colonoscopy were unrevealing. The patient had no history of dysphagia and reported no swallowing problems. The decision was made to perform small bowel wireless capsule endoscopy. The patient swallowed the capsule device without any complaints. As per standard protocol, the live viewer was checked before patient discharge. Aspiration of capsule endoscopy on the live viewer was suspected after physician evaluation (Figure 1). This image remained unchanged despite asking the patient to cough. Nine minutes later, the patient was asked to cough, and with a firm hand thrust maneuver to his midback, the capsule was expulsed. The patient remained asymptomatic. The recorded capsule images were reviewed, which demonstrated images of the capsule entering the trachea and settling at the level of the carina before expulsion (Video 1, watch the video at https://links.lww.com/ACGCR/A15).Figure 1.: Capsule endoscopy showing the (A) epiglottis, (B) respiratory tract, (C) tracheal rings anteriorly and trachealis muscle posteriorly, and (D) carina and both the main bronchus.Capsule endoscopy is a relatively safe procedure used to study obscure gastrointestinal bleeding when upper and lower endoscopies are unrevealing. However, this study is contraindicated in patients with strictures, bowel obstruction, difficulty swallowing, pacemakers, and pregnancy. It is important to screen patients for difficulty with swallowing before the wireless capsule study. To avoid capsule retention, the alternative would be direct postpyloric placement of the wireless capsule using a capsule deployment device. Swallowing dysfunction could potentially lead to aspiration of the wireless capsule device although this is a relatively rare complication. There have been previously reported cases in the literature of tracheal aspiration of wireless capsule endoscopy devices, but most of them were overtly symptomatic.1–5 Our case highlights the importance of a rare complication that can occur in patients without dysphagia and can be completely asymptomatic after capsule tracheal aspiration. Some case reports conclude or suggest that capsule endoscopy should be introduced by a delivery system in elderly patients. The reason being that these groups are at relatively higher risk of neurological diseases that could potentially impair the swallowing process.6 It is interesting that most of the reported cases were patients older than 60 years, and it is rather alarming that it can be associated with changes in the swallowing mechanisms of otherwise healthy aging adults. This is known as presbyphagia.7 In turn, the subtle changes associated with presbyphagia can lead to intermittent impaired deglutition. Especially in elderly patients, one must recognize that impaired deglutition remains a hidden threat that can lead to a complication while swallowing the capsule device. Our patient was referred to speech and swallow for further evaluation of deglutition. Therefore, it is strongly recommended that all staff involved in this procedure should be alerted to the potential risk of capsule tracheal aspiration. Major complications could occur as a consequence of capsule aspiration requiring emergent intubation and removal of the foreign body by bronchoscopy. Furthermore, prompt recognition and proper management of this complication are warranted before the patient is discharged. We proposed an algorithm approach to follow in the event of aspiration of a capsule device as an attempt to minimize complications of this uncommon event (Figure 2).1–6Figure 2.: An algorithm approach to follow in the event of aspiration of capsule endoscopy.DISCLOSURES Author contributions: FM Arroyo-Mercado wrote the manuscript and is the article guarantor. M. Martinez revised the manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.