Longest Retained Capsule in Crohnʼs Disease

Abstract

Purpose: This is a case of 24 year old male with Crohn's ileocolitis who had been followed in our gastroenterology clinic for past 6 years. He was diagnosed with Crohn's disease at age of 8 and was maintained on mesalamine. Immunemodulator therapy was started six years ago and patient had been in clinical remission until current presentation. Patient presented with complaints of acute onset nausea, vomiting and abdominal pain and underwent CT imaging which revealed small bowel obstruction with finding of a metallic object in distal ileum consistent with a retained capsule. He was conservatively treated for bowel obstruction with resolution of symptoms. The capsule was noted to be about 15 cm proximal to ileocecal valve. Previously patient had undergone capsule endoscopy (Given PillCam) six years ago to evaluate extent of Crohn's disease. The capsule study had revealed no jejunal or ileal lesions. Colonoscopy during same time had shown terminal ileitis and mild colitis. To further evaluate the finding of retained capsule, patient underwent double balloon endoscopy. Endoscopy revealed a complicated tortuous stricture 20 cm proximal to ileocecal valve. Endoscopic dilation of stricture was attempted but due to complicated nature of stricture was not successful. The capsule was noted to be more proximal to the stricture as seen on fluoroscopy images and hence not retrievable. The presence of complicated stricture was consistent with Crohn's disease stigmata. It is unlikely the capsule induced the small bowel obstruction as it had been present for past six years and no structuring disease was noted at that time. The complicated stricture in the ileum was the cause of obstruction and retained capsule was an incidental finding. Conclusions: Longest retained capsule in literature has been 2.5-3 years. This case is representative of longest retained capsule which was asymptomatic clinically. We conclude that capsule endoscopy is a safe procedure. However, in Crohn's disease, a patency capsule should be considered before capsule endoscopy. If patency capsule is not done prior to the study, a follow up abdominal x-ray should be done to exclude capsule retention.