Capsule Retention Following Capsule Endoscopy
61-year-old male with abdominal pain 15 days after capsule endoscopy. • Xray of the Week
Figure 1. What are the important findings in this case.
Figure 2. Frontal abdomen radiograph demonstrates foreign body consistent with capsule endoscopy device (pill cam) in descending colon.
Capsule Retention and Risk Factors:
Capsule endoscopy is used for evaluating small-bowel disorders, such as bleeds and Crohn disease.[1] This diagnostic procedure involves swallowing a pill-sized camera that records thousands of images of the alimentary canal including the small intestine, an area difficult to examine via traditional endoscopy. Retention of the camera-containing capsule is the main complication of capsule endoscopy.
Traditionally, capsule retention (CR) is defined as the presence of a capsule in the digestive tract for a minimum of 2 weeks. Approximately 2% of all capsule endoscopies result in CR [2] The clinical indication for capsule endoscopy is correlated with different rates of CR. Retention rates for patients post-capsule endoscopy for chronic diarrhea or abdominal pain is approximately 2%.[3] For patients with a greater likelihood of small bowel strictures, retention rates increase to 13%.[4] The highest CR rates of 10-20% are in patients being evaluated for subacute small bowel obstructions.[5,6] Use of high-dose non-steroidal anti-inflammatory drugs, previous abdominal radiation therapy, and history of small bowel restrictions generally increase the risk of CR post-capsule endoscopy.2
Imaging:
In asymptomatic patients, plain abdominal x-ray 15-days following capsule ingestion is the preferred confirmation imaging of CR. If capsule endoscopy findings suggest potential CR, then performing an abdominal x-ray 7-days post-capsule ingestion is advisable, since most capsules are excreted within 3-7 days. Capsules that reach the cecum generally are secreted as cases of colonic CR accounting for less than 1% of all retention [7]. Computed tomography (CT) could be used to determine the capsule’s location if it is difficult to do so via x-ray.
Treatment:
Asymptomatic patients are monitored initially, given that 35-50% of patients with CR naturally excrete the capsule after more than 15 days.[8,9] Surgical or device-assisted enteroscopy retrieval of the capsule is indicated for asymptomatic patients 3-6 months following capsule ingestion. For patients with inflammatory bowel disease, the use of steroids has been shown to assist the excretion of capsules in up to 20-30% of all CR cases.[2]
Importance of Prompt Management:
Patients with missed CR could develop bowel obstruction and perforation.[2] Disintegration of the capsule could expose the camera’s lithium battery to the digestive tract, increasing the risk of mucosal damage. Identifying and managing CR is important to prevent avoidable gastrointestinal complications.
References:
1. Lee HS, Lim YJ, Kim KO, et al. Outcomes and Management Strategies for Capsule Retention: A Korean Capsule Endoscopy Nationwide Database Registry Study. Dig Dis Sci. 2019;64(11):3240-3246. doi:10.1007/s10620-019-05659-7
2. Rondonotti E. Capsule retention: prevention, diagnosis and management. Ann Transl Med. 2017;5(9):198. doi:10.21037/atm.2017.03.15
3. Rezapour M, Amadi C, Gerson LB. Retention associated with video capsule endoscopy: systematic review and meta-analysis. Gastrointest Endosc. 2017;85(6):1157-1168.e2. doi:10.1016/j.gie.2016.12.024
4. Cheifetz AS, Lewis BS. Capsule endoscopy retention: is it a complication? J Clin Gastroenterol. 2006;40(8):688-691. doi:10.1097/00004836-200609000-00005
5. Cheifetz AS, Sachar DB, Lewis BS. Small Bowel Obstruction — Indication or Contraindication for Capsule Endoscopy. Gastrointest Endosc. 2004;59(5):P102. doi:10.1016/S0016-5107(04)00509-7
6. Yang XY, Chen CX, Zhang BL, et al. Diagnostic effect of capsule endoscopy in 31 cases of subacute small bowel obstruction. World J Gastroenterol. 2009;15(19):2401-2405. doi:10.3748/wjg.15.2401
7. Sachdev MS, Leighton JA, Fleischer DE, et al. A prospective study of the utility of abdominal radiographs after capsule endoscopy for the diagnosis of capsule retention. Gastrointest Endosc. 2007;66(5):894-900. doi:10.1016/j.gie.2007.06.066
8. Fernández-Urién I, Carretero C, González B, et al. Incidence, clinical outcomes, and therapeutic approaches of capsule endoscopy-related adverse events in a large study population. Rev Esp Enferm Dig. 2015;107(12):745-752. doi:10.17235/reed.2015.3820/2015
9. Rondonotti E, Soncini M, Girelli C, et al. Small bowel capsule endoscopy in clinical practice: a multicenter 7-year survey. Eur J Gastroenterol Hepatol. 2010;22(11):1380-1386. doi:10.1097/MEG.0b013e3283352ced
Eric Errampalli is a passionate medical student at the University of Missouri – Kansas City Six-Year BA/MD Program, with a steadfast commitment to becoming a radiologist. His fascination with the field stems from its integral role in healthcare and the endless possibilities for technological advancements waiting to be made. At UMKC, Eric has made significant contributions to the Radiology Interest Group, serving in various executive roles and currently as the interventional radiology chair. His leadership has inspired his peers to explore the field and discover the boundless opportunities for growth and impact. Beyond UMKC, Eric's interests have risen to a national level, as he serves on the Society of Interventional Radiology Medical Student Council Education Committee and TheRadRoom IR Team. Through these platforms, he has been instrumental in shaping the future of interventional radiology education and promoting awareness of the field among medical students.
Eric's passion for innovation extends beyond the classroom, as he strives to help drive change in the field of radiology through his medical entrepreneurial ventures. He believes that entrepreneurship can unlock untapped potential in the field and pave the way for transformative breakthroughs that can improve patient outcomes and revolutionize healthcare.
To stay up to date on Eric's journey and learn more about his work, follow Eric on Twitter @EricErrampalli and connect with him on LinkedIn www.linkedin.com/in/eric-errampalli/
Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson.
Follow Dr. Rice on Twitter @KevinRiceMD
