Conservative Management of an Impacted Capsule Within the Appendiceal Orifice

Abstract

A fifty year old female with a history of anemia presented with acute worsening of chronic abdominal pain. She admitted to some nausea but no other associated complaints. She had a normal physical exam apart from mild right quadrant abdominal tenderness with palpation. Laboratory work was significant for a hemoglobin of 11.7 g/dl. Gallbladder ultrasound and Computed Tomography scan of the abdomen were normal. Upper endoscopy revealed mild gastropathy with duodenitis. Given her prior work up, a capsule endoscopy was done to exclude concerns for a small bowel etiology such as Crohns disease. The capsule report revealed a tortuous small bowel and the cecum was not visualized on the images. As the capsule was not retrieved, an abdominal X-ray confirmed a retained capsule in the right lower abdominal quadrant. Multiple attempts were made at flushing the capsule out with purgative agents and enemas. As serial abdominal X-rays confirmed the retained capsule even after several days, colonoscopy was performed to retrieve the capsule (Fig 1). Upon endoscopic examination of the cecum, the capsule was noted to be lodged within the appendiceal orifice (Fig 2). We were able to dislodge the capsule using aggressive washing maneuvers and applying gentle pressure around the base of the capsule with the Roth net catheter. The Roth net was then used to remove the capsule from the colon. The patient did well subsequently and was discharged for outpatient follow up. Capsule endoscopy has become the accepted modality for evaluating small bowel pathology. Capsule retention is a complication with an overall incidence of 1-2%. Individuals with Crohn's disease are at highest risk for capsule retention (13%) versus obscure GI bleeding patients with lowest risk. A thorough literature review revealed one other case report of an impacted capsule that was caused by appendicitis requiring an appendectomy. We demonstrate here in this case report the conservative management of an impacted capsule within the appendiceal orifice of a patient without any known bowel pathology, which, to the best of our knowledge, has not been previously described in the literature.Figure 1Figure 2