Retention of endoscopic capsule in an umbilical hernia

Capsule endoscopy is a common method for the investigation of obscure gastrointestinal bleeding. Despite the reduced risk of complications, capsule retention is the most frequent complication, occurring in 1 % – 3 % of cases [1].

A 64-year-old woman, obese and hypertensive, with indeterminate colitis in remission for several years, presented to the emergency department with hematochezia. She reported a history of recent surgery to varicose veins of the lower limbs and post-operative treatment with diclofenac. On physical examination, she appeared pale; the rest of the examination was unremarkable except for a reducible incoercible umbilical hernia. Analytically, the patient presented hemoglobin of 5.6 g/dL (12 – 16 g/dL).

Upper endoscopy and colonoscopy showed no lesions, and the patient was admitted for investigation. The computed tomography (CT) enteroclysis was normal except for an umbilical hernia with a bowel loop within, without signs of strangulation ([Fig. 1]).

Fig. 1 Computed tomography (CT) enteroclysis showing the umbilical hernia (yellow arrow) with a bowel loop within.

Capsule endoscopy (PillCam SB 2; Given Imaging, Yoqneam, Israel) was then performed; it showed no changes in the mucosa up to the jejunum, where after 1 hour and 20 minutes the capsule remained stagnant until the end of the battery’s life ([Fig. 2]).

Fig. 2 Image captured by capsule endoscopy at the site of stagnation.

The patient remained asymptomatic. A small-bowel radiograph with water-soluble contrast showed the capsule retained in the umbilical hernia and ruled out stenosis or signs of small-bowel obstruction ([Fig. 3]).

Fig. 3 Small-bowel radiograph with water-soluble contrast showing retained capsule (white arrow) in relation to an umbilical hernia (yellow arrow).

After 16 days of capsule retention, a hernioplasty was performed and the capsule was spontaneously expelled afterwards.

Retention of an endoscopic capsule is a rare complication. There are a few case reports of capsule retention in different types of digestive diverticulum [2] [3] [4] but, to the best of our knowledge, this is the first case of capsule retention in an umbilical hernia. Current recommendations do not consider these entities as contraindications for capsule endoscopy [5], but the gastroenterologist should keep in mind the potentially increased risk of capsule retention.

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References

• 1 Liao Z, Gao R, Xu C, Li Z S. Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review.  Gastrointest Endosc. 2010;  71 280-286
• 2 Ordubadi P, Blaha B, Krampla W et al. Capsule endoscopy with retention of the capsule in a duodenal diverticulum.  Endoscopy. 2008;  40 247-248
• 3 Giday S A, Pickett-Blakely O E, Buscaglia J M, Mullin G E. Capsule retention in a patient with small-bowel diverticulosis.  Gastrointest Endosc. 2009;  69 384-386
• 4 Tanaka Y, Motomura Y, Akahoshi K et al. Capsule endoscopic detection of bleeding Meckel’s diverticulum, with capsule retention in the diverticulum.  Endoscopy. 2010;  42 199-200
• 5 Ladas S D, Triantafyllou K, Spada C. et al . European Society of Gastrointestinal Endoscopy (ESGE): recommendations (2009) on clinical use of video capsule endoscopy to investigate small-bowel, esophageal and colonic diseases.  Endoscopy. 2010;  42 220-227