A 54-year-old female presented to our surgical service with a 4-month history of intermittent abdominal pain, cramping, and nonbloody diarrhea. She reported a weight loss of 38 pounds over this time. According to the patient, the pain was intermittent and involved the lower abdomen. She had not recently taken any medications or antibiotics. The patient denied any travel outside of the country and had a municipal water supply. No one else in her family had been sick with similar complaints. Her surgical history included a cesarean section and ectopic pregnancy.
CT of the abdomen and pelvis was performed, along with laboratory evaluation. The CT scan showed a 6.5-cm segment of distal ileum exhibiting circumferential wall thickening and mesenteric inflammatory changes (Figure 1). The impression from radiology was chronic enteritis, either of bacterial etiology or Crohn disease. Laboratory evaluation revealed a potassium level of 2.6 mEq/L, a normal WBC count, and hemoglobin and hematocrit levels of 9.4 g/dL and 29.9%, respectively. Results from stool specimens for ova and parasites, culture and sensitivity, and Clostridium difficile were negative. The patient was treated empirically with oral metronidazole (Flagyl) and was advised to continue with a clear liquid diet. Upper and lower endoscopies were scheduled to allow visualization of as much of the small bowel as possible.
Follow-up complications Eight months later, the patient returned for a follow-up visit. Flare-ups of pain and severe diarrhea had occurred three times within the past 8 months. Since small bowel biopsy had previously been impossible, a tissue diagnosis of Crohn disease was not confirmed. As the patient was less symptomatic and inflammation was assumed to be under control, another attempt at a lower endoscopy was scheduled. Unfortunately, the same problem occurred, and inflammation around the ileocecal valve prohibited the scope from passing into the small bowel. A decision was made to send the patient for wireless capsule endoscopy (CE) of the small bowel utilizing PillCam.
The patient swallowed the pill without difficulty, and the small bowel could be visualized clearly. Areas of significant acute inflammation, edema, and deep ulceration were seen in the mid-small bowel after 3 hours and 40 minutes. Another concentrated area of inflammation was visualized about 6 hours into the procedure (Figure 2). The images did not reflect whether the CE device had exited the small bowel because definitive colon images were not seen. To assure clearance of the device, a kidney-ureter-bladder (KUB) radiograph was ordered.
One week after swallowing the CE device, the patient returned for the KUB radiograph. A metallic electronic radiopaque focus was seen in the left hemipelvis and was compatible with what could be a CE device, as noted in the history given to radiology (Figure 3). No bowel distention or ileus was noted, and moderate fecal debris were seen. The patient did not want surgical intervention and chose to wait, as she was hopeful that she would pass the device on her own. One week after the KUB radiograph, a comparison film was obtained that showed the radiopaque CE device still present in the pelvis with a similar position as before, indicating a possible obstruction. An exploratory laparotomy with possible resection or strictureplasty was suggested. Risks, benefits, complications, and alternatives were discussed with the patient, and she gave consent to proceed.
