Endoscopic Approaches to Retained Capsule Endoscopy

Purpose: To present cases of retained capsule endoscopy and endoscopic approaches to their management. Case 1: A 31-year-old male with a history of Crohn's disease (CD) underwent capsule endoscopy (CE) to assess possible worsening of small bowel (SB) disease activity. CE showed numerous SB strictures. An abdominal x-ray was obtained which showed a retained capsule. A small bowel follow-through (SBFT) showed the capsule at 15 cm from the ileocolonic anastomosis. Thus, a colonoscopy was done to retrieve the capsule. At colonoscopy ileal strictures were balloon dilated. After dilation, the capsule was retrieved with a Roth Net® Case 2: A 61-year-old male with a history of CD and multiple SB resections underwent CE for evaluation of iron deficiency anemia. CE showed intermittent areas of nodular and erythematous mucosa with ulcerations in the ileum. Five days after CE he developed emesis. Abdominal x-ray showed a retained capsule in the SB. However, the location could not be identified due to his history of multiple surgeries. He underwent colonoscopy, which showed a stricture at the ileocolonic anastomosis but no capsule in the distal ileum. Push enteroscopy (PE) was then performed which showed the capsule in the SB. A polypectomy snare was used to grasp the capsule. The capsule dislodged into the stomach as it was being retrieved. Then, with a gastroscope using a Roth Net®, the capsule was removed. Discussion: Endoscopic retrieval of a retained capsule can be successfully performed after medical management with steroids or purgatives has failed. Advanced imaging modalities such as SBFT are sometimes helpful in determining which endoscopic approach should be attempted first (i.e., anterograde versus retrograde). If a retrograde approach is utilized and a stricture is encountered, then pre-retrieval through the scope (TTS) balloon dilation may be required. Also, if one approach (i.e., retrograde) initially fails at localizing the retained capsule, then another approach (i.e., anterograde) should be attempted before sending a patient to surgery. In patients with altered bowel anatomy from prior surgeries, deciding which approach to initially utilize may be unclear. In institutions where single or double balloon enteroscopy is not available, PE is a viable alternative before sending a patient to surgery.