Journal of the New Zealand Medical Association, 13-February-2009, Vol 122 No 1289
A rare complication of wireless capsule endoscope
Esra Venecourt-Jackson, Ishy Maharaj
As a novel investigative tool, the introduction of wireless capsule endoscopy (CE) less than a decade ago has already proven to be a major milestone in gastrointestinal (GI) medicine. It is the most major breakthrough since flexible endoscopy first made possible direct visualisation of the upper and lower GI tracts more than three decades ago. However the small intestine remained the "dark zone" of the GI tract until CE finally opened it to direct visualisation.
As with any new investigative tool, the indications for capsule endoscopy have gradually broadened, and so has knowledge about its limitations, contraindications, and complications with increasing worldwide utilisation. This case illustrates a rare complication of capsule endoscopy.
A 72-year-old Caucasian female was admitted to North Shore Hospital, Auckland in January 2007 with malaena and a low haemoglobin. She was on maintenance treatment with warfarin (since 2005) for cardiac disorders which included ostium primum and ostium secundum atrial septal defects repaired in 1991, a St Jude’s mitral valve placement in 2005 for severe mitral regurgitation, paroxysmal atrial fibrillation, and sick sinus syndrome with pacemaker insertion in 2003. Her other regular medication included frusemide, cilazapril, spironolactone, aspirin, and pantoprazole. She was investigated for intermittent dysphagia involving the upper oesophagus in November 2006 when barium studies demonstrated a Zenker’s diverticulum.
Gastroscopy performed the day after admission excluded a source of bleeding in the upper GI tract. The endoscopist noted the presence of a Zenker’s diverticulum and of a hiatus hernia. No cause for GI bleeding was found at colonoscopy performed a few days later but transported blood was found in the colon, pointing to bleeding from the small bowel. The presence of diverticula was noted. Intermittent bleeding persisted, requiring repeated blood transfusions. Therefore capsule endoscopy was performed. However no images were demonstrated when the study was analysed, indicating that the capsule had not entered the small bowel.
Subsequent X-rays of her chest and neck demonstrated that the capsule had in fact lodged in the Zenker’s diverticulum. Attempted endoscopic removal of the capsule was unsuccessful. The capsule was removed a few days later under general anaesthesia by an ENT surgical team. Repeat CE after endoscopic placement of the capsule into the duodenum was offered but she declined because she had concerns about the possibility of lodgement lower down in the GI tract. CT enteroclysis was therefore performed but failed to demonstrate any pathology to explain her obscure GI bleeding. Fortunately she thereafter stopped bleeding spontaneously and bleeding has not recurred for over a year since discharge from hospital.
While obscure GI bleeding remains the principal indication for capsule endoscopy, it is proving to be useful in the diagnosis and follow-up of varied gastrointestinal disorders, especially small bowel Crohn’s disease.1 Other indications include detection of small bowel tumours, surveillance for tumours in patients with familial adenomatous polyposis and Peutz Jeghers syndrome, diagnosis of coeliac disease, gastroesophageal reflux disease, and Barrett’s oesophagus since the introduction of PillCam ESO, site of bleeding in patients with portal hypertension in whom gastroscopy is normal, and imaging of the colon (with the development of PillCam colon).
Progressive technological refinement, longer battery life and rising worldwide utilisation are some of the factors leading to increased sensitivity and accuracy of diagnosis using this new tool. At the same time there has been a parallel increase in knowledge about the contra-indications and complications of this procedure.
The main contraindication for capsule endoscopy is suspected or known gastrointestinal obstruction or stricture.2 Other contraindications include motility disorders (achalasia, intestinal pseudo-obstruction) and swallowing disorders. Relative contraindications are cardiac pacemakers and implanted cardiac defibrillators (although there is some information about the safety of CE in patients with these cardiac devices—see ref 3 and 4).
Patients with higher risk of capsule retention include those with chronic NSAID use, extensive Crohn’s disease, abdominal radiation injury, prior major abdominal surgery, and prior small bowel resection.
A very rare complication of capsule endoscopies is aspiration into the bronchial tree. Less than 10 cases have been reported so far. The average risk of capsule detention is 0.75%, the risk in suspected Crohn’s disease 1%, known Crohn’s disease 5%, obscure GI bleeding 1.5%, and suspected small bowel obstruction 21%.5
This case illustrates a rare complication of capsule endoscopy, namely capsule retention in a Zenker’s diverticulum. A literature search indicates that this is the first documented case of this complication in New Zealand.
A few reports are documented from other parts of the world. A case in Minnesota USA6 describe a 73-year-old man with a history of symptomatic Zenker’s diverticulum was investigated using capsule endoscopy. Unfortunately the capsule became lodged in the diverticulum. It was removed endoscopically and reinserted using an over-tube placed in a Savory dilator, thus allowing the study to be completed.
In a letter to the editor7 the issue of whether Zenker’s diverticulum is a contraindication for wireless endoscopy was addressed. The authors also presented a case of a 73-year-old female in whom the capsule became lodged in the Zenker’s diverticulum. They also recommended that in these patients endoscopic guidance should be employed to place the capsule directly into the stomach using a conventional endoscope and a polypectomy snare.
Another case was recorded in Norway8 of a 74-year-old female undergoing capsule endoscopy as investigation for melaena and severe iron deficiency anaemia. As she was known to have a 3 cm Zenker’s diverticulum, the capsule was fixed to the outside of a paediatric endoscope using an external polypectomy snare. The capsule was then passed into the stomach, confirmed by retroflexed viewing.
The risk of retention in the oesophagus could be minimised by making efforts to exclude swallowing and motility disorders. If suspected, these disorders should be investigated before capsule ingestion is attempted.
In the upper GI tract, capsule retention can occur at the cricopharyngeus, bronchial tree, Zenker’s diverticulum, peptic stricture of the oesophagus, achalasia, oesophageal-jejunal anastamosis, pylorus, and duodenal bulb. In patients suspected or known to have these disorders, endoscopic placement of the capsule beyond the stomach will allow this valuable tool be used in individuals with these relative contraindications. Similarly the risk of capsule retention in the small bowel could be significantly reduced by use of the AGILE Patency capsule prior to performing PillCam endoscopy in patients with possible stricture and/or bowel obstruction. This capsule will dissolve if retained in a stricture or will be deformed or fragmented when excreted if it has passed a stricture. PillCam passed uneventfully in patients in whom the AGILE Patency was excreted intact.
This simple procedure helps physicians determine that the PillCam capsule will pass down the gastrointestinal tract without being retained.9 Recent studies of the AGILE patency procedure demonstrate positive predictive value of 100% for confirming free passage of the PillCam capsule.9,10
Capsule endoscopy is an exciting new tool in the investigation of the GI tract. With increasing worldwide utilisation, indications for capsule have broadened steadily since it was first introduced for the investigation of obscure GI bleeding and so has awareness of possible contraindications and complications, techniques to decrease the risk of these complications, and methods of dealing with them should they occur.
Author information: Esra Venecourt-Jackson, Medical Registrar; Ishy Maharaj, Gastroenterologist; Gastroenterology and General Medicine Departments, North Shore Hospital, Auckland
Correspondence: Dr Esra Venecourt-Jackson, General Medicine Department, North Shore Hospital, Private Bag 93-503, Takapuna,, North Shore City 0740, New Zealand. Email: email@example.com
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