S4576 Swallowed but Not Forgotten: A Capsule’s Journey to Obstruction

Introduction: Capsule endoscopy (CE) is a key modality in evaluating obscure gastrointestinal bleeding, offering direct visualization of the small bowel in a non-invasive manner. While generally safe, CE is not without risks. One of the most serious complications is capsule retention, which can lead to small bowel obstruction or, less commonly, perforation. Though rare—occurring in 2–8% of cases—retention poses a clinically significant threat that requires close monitoring, particularly in patients with potential small bowel pathology. Case Description/Methods: A 62-year-old woman with a history of recurrent gastrointestinal (GI) bleeding underwent CE following unremarkable colonoscopy and an esophagogastroduodenoscopy that showed 2 non-bleeding gastric ulcers. Five days later, she presented with diffuse abdominal pain, bloating, nausea, and exertional shortness of breath. A computed tomography scan showed capsule impaction in the right lower quadrant with proximal bowel dilation and free air, suggesting perforation. Surgical consultation was obtained. At laparotomy, a 30 cm segment of ileum was resected. The capsule was freely mobile but just proximal to a strictured segment with creeping fat, raising concern for chronic inflammatory disease. Histology confirmed a fibrotic stricture. The patient had an uncomplicated recovery and was discharged home 4 days postoperatively. Discussion: While CE is widely used and generally well tolerated, capsule retention remains a known complication, especially in those with unrecognized strictures. Retention is defined as the capsule remaining in the GI tract for over 2 weeks or requiring removal due to symptoms. Common causes include Crohn’s disease, nonsteroidal anti-inflammatory drug enteropathy, tumors, or prior radiation. This patient had no known inflammatory bowel disease, though intraoperative findings suggested subclinical Crohn’s. Symptoms of retention may be delayed, with obstruction appearing days to weeks later. Any patient with new abdominal symptoms after CE should undergo prompt imaging. In this case, early recognition and surgical intervention prevented greater morbidity. Pre-procedural screening—via cross-sectional imaging or a patency capsule—can help identify high-risk patients. Patients should also be counseled about this complication. This case underscores the need for caution when using CE in patients with possible small bowel disease and highlights the importance of post-procedural monitoring. Though rare, capsule retention can become a surgical emergency if not quickly addressed.