Capsule endoscopy has become an important adjunct to identify obscure gastrointestinal bleeds and small intestinal disease. Contraindications to this procedure include intestinal obstruction and inability to swallow. Newer devices are now being utilized to decrease the risk of aspiration. We present a case of video capsule endoscopy resulting in pulmonary complications.
A 74 year old white male was transferred from an outside hospital for evaluation of gastrointestinal bleeding. The patient had both upper and lower endoscopy at the outside hospital with no bleeding source found. The patient had a past medical history of squamous cell cancer of the head and neck treated with right mandibulectomy, fibular flap reconstruction, tracheostomy which was later reversed, and radiation therapy. As a result, his ability to swallow was impaired and the patient was scheduled for direct endoscopic placement of a video capsule. During the procedure, the capsule along with the delivery housing was prematurely dislodged. The device was then incorrectly localized on radiography as being in the esophagus. The patient had no post procedure complications, complaints of shortness of breath, hoarseness or changes in his pulse oximetry. The next day, the patient had repeat upper endoscopy to localize the pill. The patient, however, was found to have an active duodenal bleed that was refractory to endoscopic therapy and was emergently taken to the operating room.Once intubated, the patient had prolonged episodes of hypoxia with PaO2 of 47mmhg on 100% oxygen. Intermittent suction resulted in transient improvements in hypoxia. After surgery for the duodenal ulcer, an emergency x-ray revealed complete opacification of the left hemithorax and the capsule in the left main stem bronchus. The pulmonary service was emergently consulted and bronchoscopy revealed complete obstruction of the left main stem bronchus by a video capsule. Due to its size and shape, the capsule proved to be too large for removal by basket, Roth net or forceps. Instead, a balloon catheter was expanded distal to the capsule and successfully used to dislodge it forward to the carina. ENT and cardiothoracic surgery were consulted for further assistance. Through the use of several different techniques, including suspension laryngoscopy and various inflatable catheters, the capsule was eventually removed by forceps from the oropharynx. The patient was transferred to the SICU in stable condition and later extubated without sequelae.
This is a rare case of pulmonary complication from capsule endoscopy. To our knowledge, this is the first case associated with severe hypoxia or lung opacification and only the second involving aspiration to the left lung. Of the previous cases, 4 involved patients who eventually swallowed the capsule, 4 required bronchoscopic removal and one required retrieval from the cricopharyngeus. We hypothesize that our case was complicated by positive pressure ventilation used in the operating room that forced the capsule distally until it completely occluded the left main stem bronchus. The improvements in hypoxia from suctioning were likely due to ball-valve effect of the capsule.Although the capsule was dislodged from the left main stem via flexible bronchoscopy, complete removal of the device was not possible without further assistance. Due to the patient’s surgically altered upper airway, rigid bronchoscopy was difficult to perform. One previous case used a Roth net to retrieve the capsule, but because of the additional size of the housing surrounding our device, this was not feasible. Our case highlights the need for potential protocols or new techniques for bronchoscopic removal of video capsules or the need to alter the design of these devices for easier retrieval.
Gastrointestinal complications, although rare, are the most common complications of capsule endoscopy. Our case highlights pulmonary complications from video capsule aspiration.
Adil Degani, No Financial Disclosure Information; No Product/Research Disclosure Information