Holding the Record for Retention of an Endoscopy Capsule

Wireless capsule endoscopy (WCE) is an important tool for direct visualization of the small bowel without associated risks of radiation or sedation in youth who are able to swallow the capsule. The Food and Drug Administration has approved WCE usage in children for evaluation of gastrointestinal bleeding and small bowel disease. Although noninvasive, WCE carries certain risks, particularly capsule retention. To our knowledge, we describe the longest reported case of capsule retention. A 10-year-old well-appearing boy with a history of surgically repaired congenital duodenal atresia and pyloric stenosis as well as intestinal adhesions requiring lysis presented to his primary care pediatrician for evaluation of acute abdominal pain, which subsequently resolved during a 2-day period. His pediatrician performed an abdominal x-ray and found a foreign body consistent with a WCE at the right abdomen (Fig. 1). Further interview revealed that the patient was admitted at 2 years old for 2 months at an out-of-state institution for the evaluation of gastrointestinal bleeding. WCE evaluation during that admission revealed multiple small arteriovenous malformations isolated to the small bowel; these were managed with supportive care and blood transfusion. During the patient's hospital stay, the patient's family reported multiple changes in physicians, and ultimately the patient was discharged without WCE passage. Patient was initially studied with serial abdominal x-rays until he was lost to follow-up 7 months after the WCE placement.FIGURE 1: Supine AP plain radiograph of the abdomen. Retained wireless endoscopy capsule projects over the right mid abdomen (vertical arrowhead).The patient was referred to our pediatric gastroenterology clinic for intestinal foreign body evaluation. At the clinic visit, the patient was asymptomatic. Physical examination was unremarkable outside of positive stool guaiac testing. Body mass index was 87% (19.7 kg/m2). Hemoglobin was 13.3 g/dL with normal red blood cell indices. A computed tomography revealed a radiodense body consistent with the WCE in the proximal small bowel and distention of small bowel loops consistent with partial obstruction from adhesions (Fig. 2). The patient underwent surgical consultation to undergo surgical removal of the retained WCE. To date, the family has, however, decided against surgical intervention because of lack of patient symptoms and ongoing fear of surgical complications. An alternative to surgical removal of WCE is endoscopic removal. The case was, however, reviewed with both local and national experts and it was felt that removal should be deferred given that the benefits may not outweigh the risks of intervention. We have adopted a management plan of watchful waiting and have informed the family of warning signs that would prompt urgent reevaluation.FIGURE 2: Transaxial computed tomography image of the mid abdomen with intravenous contrast. Retained wireless endoscopy capsule in the right mid abdomen (vertical arrowhead). Multiple adjacent loops of mildly dilated small bowel in the right mid abdomen with mild bowel wall thickening (horizontal arrows). It is not clear whether the wireless endoscopy capsule is intraluminal or extraluminal in location.In order to ensure accurate transfer of information between care providers and prevent future complications, the patient was prescribed a medical alert bracelet detailing the WCE retention and the importance of avoiding magnetic resonance imagings in the future. In addition, the family was cautioned regarding the dangers of magnet coingestion. The family was advised to routinely follow-up with pediatrician for intermittent complete blood cell count and heme-occult stool monitoring of clinically significant gastrointestinal bleeding. DISCUSSION The most significant complication of WCE is capsule retention. The International Conference on Capsule Endoscopy consensus group defined WCE retention in pediatrics as having a WCE remain in the digestive tract for a minimum of 2 weeks (1). A recent meta-analysis of WCE retention prevalence reports gastric and small bowel retention rates in 0.4% and 1.8%, respectively, pediatric patients (of 1013 WCE) (2), with the highest rates found in those procedures performed for evaluation of Crohn disease. As in many cases of WCE retention, our patient was asymptomatic even with evidence of ongoing partial small bowel obstruction on computed tomography imaging that may be caused by the adhesions or the retained WCE. Although surgery is not being performed in our patient, surgery has been performed in cases for WCE retention when endoscopic removal is not possible. In another case of long-term (2 years) unrecognized retention of a WCE with symptomatic intermittent bowel obstruction, exploratory laparotomy was performed and revealed an intraluminal capsule retained because of a near-obstructive carcinoid tumor (3). Although our patient does not have known inflammatory bowel disease, he does have a history of prior surgery and small bowel adhesions. Given the risk of WCE retention, the patency capsule (PC) was developed by Given Imaging in 2006 (approved for use in pediatric patients in 2009) to evaluate for obstruction or strictures in the gastrointestinal tract before evaluation by WCE. Our patient may have benefited from PC screening before WCE had it been available. Hand-off of patient care affects continuity and quality of patient care, and patient safety. In this case, hand-off issues may have contributed to the lack of follow-up regarding the WCE. In an effort to decrease communication errors during hand off, the Joint Commission on Accreditation of Hospital Organizations has mandated that hospitals implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions (4). Multiple mnemonics and checklists have been developed to standardize patient hand-offs; however, no single hand-off method is used uniformly across all institutions. This case highlights the need for universal standardized protocols on how to ensure WCE passage and how to deal with WCE retention including relevant patient and family education regarding expected evacuation time frame and guidelines for management of retained capsules. An important consequence of WCE retention is the need to avoid magnetic resonance imaging and magnet coingestion given the critical risk of intestinal perforation. We hope to avoid this potential situation through both patient education and the use of a medical alert bracelet. In addition, the patient will need and undergo continued monitoring for potential bowel obstruction. Should the retained capsule disintegrate, none of the capsule components are toxic. In conclusion, we present an ongoing case of WCE retention (8 years and counting) in an asymptomatic pediatric patient. Our case highlights surgical history as a risk factor for WCE retention, the need for universal protocols to monitor for WCE retention and the importance of family education. Potential organizational and care interventions are reviewed to prevent similar events in the future. Addendum: The mother of the child, now aged 12 years, has reported that repeat films at an outside institution no longer demonstrate the presence of the WCE.