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| Journal of the New Zealand Medical Association,
13-February-2009, Vol 122 No 1289
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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.
Case reportA 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.
DiscussionWhile 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
ConclusionCapsule 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: e.venecourt@gmail.com
References:
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