Summary: An 84-year-old man on anticoagulation for atrial fibrillation was admitted to the hospital for evaluation and treatment of anemia and melena. Gastroenterology was consulted; a colonoscopy and EGD were performed, but did not demonstrate a source of bleeding. Video capsule endoscopy (VCE) was recommended and performed. The patient experienced a brief episode of choking and gagging when the capsule was administered. However, he stated the capsule then went down his esophagus, and he denied symptoms during the 8-hour study.
Summary: Review of the PillCam SB video demonstrated aspiration of the capsule shortly after administration. The capsule remained in a bronchus for the duration of the recording. A portable chest radiograph confirmed the location of the capsule within a right bronchus. Cardiothoracic surgery performed a rigid bronchoscopy with successful retrieval of the video endoscope.
Aspiration of PillCam SB into the right lower lobe bronchus
On review of the study, the video capsule appeared to bounce around in the pharynx a few times before entering the trachea and moving to a bronchus, where it remained for the duration of the recording (Figure 1). A portable chest radiograph demonstrated a radiopaque foreign body in the right lower lobe bronchus (Figures 2A and 2B). A chest radiograph, taken after a diagnostic and therapeutic procedure, demonstrated absence of the previously described foreign body. A specimen radiograph was also obtained (Figure 3).
Cardiothoracic surgery was consulted following review of the recorded video study and initial chest radiograph. A rigid bronchoscopy was then performed. Interestingly, the physician who performed the bronchoscopy reported the capsule was initially identified within the left lower lobe bronchus. The capsule was grasped and being removed to the level of the trachea when it slipped and fell into a right bronchus. After 90 minutes of repeated attempts to remove the video endoscope, the capsule was successfully grasped and removed via a snare.
Indications for video capsule endoscopy (VCE) include evaluation of obscure gastrointestinal bleeding (OGIB) after exclusion of an upper gastrointestinal or colonic source following EGD and colonoscopy, as well as evaluation of Crohn’s disease.1 VCE is contraindicated in patients with known or suspected gastrointestinal obstruction, strictures or fissures, as well as in patients with Zenker’s diverticulae, swallowing disorders, and pregnancy. Individuals who are not surgical candidates and those who have undergone multiple prior abdominal surgeries are also excluded.2
Complications are rare. Several studies reported a 1% to 5% incidence of retention, most commonly secondary to strictures or diverticulae. These complications required surgical removal when the video endoscope was beyond the reach of routine endoscopy.3-5 Several reports have documented aspiration of the capsule that is sometimes symptomatic and sometimes asymptomatic, as in our patient’s case.6-8
Fleischer, et al., suggest specifically questioning the patient about difficulties swallowing solid foods and pills.9 Following confirmation of aspiration, our patient did state occasional difficulty swallowing pills, however, he denied any prior episodes of known aspiration. Sinn, et al.,suggest preliminary evaluation with a video esophagram in patients with a history or risk of aspiration.7 They also state that the video endoscope should be endoscopically placed in the duodenum with an overtube in cases of urgent need for the procedure.
As with the case reports cited previously, our patient did not have an adverse outcome, as the capsule was removed without complication.
- Eliakim R. Wireless capsule video endoscopy: Three years of experience. World J. Gastroenterol. 2004;10:1238-1239.
- Ali A, Santisi JM, Vargo J. Video capsule endoscopy: A voyage beyond the end of the scope. Cleve Clin J Med. 2004;71: 415-425.
- National Institute for Clinical Excellence: Interventional procedure overview of wireless capsule endoscopy. January 2004. Available at: http://www.nice.org.uk/guidance/index. jsp?action=article&o=31215. Accessed February 15, 2011.
- Swain P. Wireless capsule endoscopy. Gut. 2003;52: iv48-50.
- Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: Report of 100 consecutive patients. Gastroenterology. 2004;126:643-653.
- Schneider AR, Hoepffner N, Rosch W, Caspary WF. Aspiration of an M2A capsule. Endoscopy. 2003;35:713.
- Sinn I, Neef B, Andus T. Aspiration of a capsule endoscope. Gastrointest Endosc. 2004;59: 926-927.
- Tabib S, Fuller C, Daniels J, Lo S. Asymptomatic aspiration of a capsule endoscope. Gastrointest Endosc. 2004;60: 845-848.
- Fleischer DE, Heigh RI, Nguyen CC, et al. Videocapsule impaction at the cricopharyngeus: A first report of this complication and its successful resolution. Gastrointest Endosc. 2003;57: 427-428.