Small Bowel Obstruction In A Crohn'S Disease Patient With Chronic Pillcam Retention

INTRODUCTION: In patients with suspected Crohn’s disease (CD) with inconclusive ileocolonoscopy and imaging, and no evidence of small bowel obstruction (SBO), video capsule endoscopy (VCE) is recommended. Occasionally, patients with suspected CD but without prior obstruction may develop chronic VCE retention and SBO. CASE DESCRIPTION/METHODS: A 53-year-old female presented to the ED with acute worsening of 2 years of intermittent, crampy lower abdominal pain, occasional nausea, vomiting, diarrhea, and 30 lb. weight loss. Her abdominal examination was benign. Abdominopelvic computerized tomography (CT) scan showed terminal ileitis. Her symptoms improved conservatively. Later, outpatient colonoscopy showed erythematous mucosa in the terminal ileum (Figure 1) with normal biopsies. CT enterogram confirmed terminal ileal thickening (Figure 2A). For more definitive diagnosis of suspected CD, patency capsule study was performed to determine safety of VCE. Subsequent X-ray abdomen showed the patency capsule overlying the midline pelvis (thought to be in the rectum, Figure 2B). VCE showed findings consistent with moderate to severe CD (Figure 3). She was started on budesonide and infliximab. Serial abdominal X-rays over the next 4-months showed persistent asymptomatic PillCam retention in the small bowel (Figure 2C). Five months after VCE, she presented to the ED with severe infra-umbilical pain, abdominal distension, nausea and vomiting. Abdominal X-ray showed prominent air-fluid levels in the left upper quadrant suggesting partial SBO (Figure 2D). Abdominal CT scan showed active CD of the terminal ileum (Figure 2E), resulting in obstruction and dilation of the fluid filled small bowel loops proximally containing the PillCam (Figure 2F). She was started on prednisone, with resolution of symptoms. Two weeks after discharge, she was doing well, and was recommended prednisone taper, increased infliximab dose, and follow-up with surgery for consideration of surgical resection of ileal CD and removal of PillCam if she fails maximal medical therapy. DISCUSSION: In patients with symptoms of CD, ileocolonoscopy with biopsies and imaging studies are performed to confirm diagnosis. For inconclusive cases, VCE is recommended if there is no evidence of SBO on imaging. Atypically, even without prior obstruction on imaging, patients may develop chronic video capsule retention and later present with SBO. Patients failing maximal medical therapy may ultimately require surgical intervention.Figure 1.: Colonoscopy showing narrowed mucosa at the ileocecal valve (A) and erythematous mucosa in the terminal ileum (B).Figure 2.: A) Computerized tomography (CT) enterogram showing asymmetric, moderate to severe segmental mural thickening of the terminal ileum with associated hyperenhancement, mural stratification, perienteric fat stranding and venous congestion. B) X-ray abdomen performed 30-hours after the ingestion of patency capsule showing the patency capsule overlying the midline pelvis (thought to be in the rectum). C) X-ray abdomen 4-months after video capsule endoscopy showing retained video capsule in the midline (possibly in the ileum). D) X-ray obstruction series (erect view) showing small bowel loops in the left upper abdomen measuring 3.7 cm in diameter with prominent air fluid levels. E) CT abdomen/pelvis with intravenous contrast showing moderate wall thickening, mucosal enhancement, mural stratification, and surrounding infiltration of fat involving the terminal ileum. F) Obstruction and dilation of fluid-filled loops of small bowel more proximally containing the video capsule.Figure 3.: Video capsule endoscopy performed using PillCamTM SB3 Capsule revealing significant focal and segmental enteritis, with ulceration (A and B), edema and stenosis (C and D) in the mid-distal small bowel consistent with Crohn’s disease of moderate to severe activity.