Interact CardioVasc Thorac Surg 2009;8:568-570. doi:10.1510/icvts.2008.190058
© 2009 European Association of Cardio-Thoracic Surgery
Negative results - Thoracic non-oncologic |
Asymptomatic bronchial aspiration of a video capsule
Tiphaine Guy,
Stephane Jouneau,
Pierre-Nicolas D'Halluin and
Herve Lena*
Service de Pneumologie, Hôpital Pontchaillou, Centre Hospitalier et Universitaire de Rennes, 2 rue Henri Le Guilloux, 35000 Rennes, France
Received 6 August 2008;
received in revised form 8 December 2008;
accepted 10 December 2008
*Corresponding author. Service de Pneumologie, Hopital Pontchaillou, 35033 Rennes, France. Tel.: +33 299282478; fax: +33 299282480.
E-mail address: herve.lena{at}chu-rennes.fr (H. Lena).
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Abstract
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Aspiration is a rare complication of video-capsule endoscopy. We report a case of asymptomatic aspiration of the capsule in a 90-year-old man. The diagnosis was obtained by the images taken by the capsule. Rigid bronchoscopy was used to remove the capsule. Recommendations to prevent this complication are: (1) Patients with swallowing disorders should have the capsule placed into the duodenum at the time of upper endoscopy. The capsule should never be placed in the stomach because of prolonged emptying times following endoscopy and IV sedation. (2) If a patient appears to have difficulty swallowing the capsule after two or three attempts, the capsule should be placed endoscopically. (3) When real-time capsule location is more readily available, the abdomen can be scanned after the initial ingestion to be sure that the capsule reached the stomach.
Key Words: Video capsule; Aspiration; Bronchoscopy
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1. Introduction
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Investigation of the small bowel was limited to radiographic studies or push enteroscopy. Since 2001, the diagnosis of small-bowel disorders has been revolutionized by the apparition of wireless capsule endoscopy [1]. The most frequent complication of this technique is retention [2]. Five cases of aspiration have previously been reported [3–7]. To our knowledge, our report is the first of a completely asymptomatic aspiration of a video capsule in a 90-year-old man successfully treated by rigid bronchoscopy.
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2. Case report
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A 90-year-old man, with only an ischemic stroke in 2006 without sequelae in his past medical history, presented with melena complicated by anemia. He was transfused and underwent gastroscopy, colonoscopy and abdomino-pelvian CT-scan with contrast. No abnormality was found. Therefore, a video-capsule endoscopy was decided to find the origin of the bleeding. The patient swallowed the capsule with water in front of the gastroenterologist without cough. The day after, the film revealed the bronchial localization of the video capsule (Video 1) confirmed by the chest X-ray (Fig. 1). The patient was completely asymptomatic with a pulsed oxygen saturation of 96% in room air. The video capsule was removed by rigid bronchoscopy with stone basket under general anesthesia without any complication (Fig. 2 and Video 2). The patient did not experience any relapse of intestinal bleeding, therefore, it was decided no further investigation was necessary.
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3. Discussion
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Since 2001, wireless capsule endoscopy has allowed direct non-invasive mucosal investigation of the small bowel and, as a result, has revolutionized the diagnosis and management of small bowel disorders, especially gastro-intestinal bleeding after negative gatroscopy and colonoscopy, Crohn's disease, assessment of celiac disease and familial polyposis syndrome [1]. The capsule endoscope is a 26x11 mm capsule containing a battery-powered complementary metal oxide silicon imager, a transmitter, antenna and four light emitting diodes. The imager is activated by removal of the capsule from its magnetic holder and takes two images per second through the transparent plastic dome of the capsule. The capsule is swallowed and is propelled through the intestine by peristalsis. Images taken by the capsule are transmitted via eight sensors, fixed to a belt with a battery powered data recorder attached to the abdominal wall of the patient. The equipment is removed after 8 h (the approximate battery life) by which time the capsule has reached the cecum in 85% of cases.
Capsule endoscopy allows complete small bowel examination in 90% of cases compared to 62.5% for endoscopy procedures. Diagnostic is obtained for 59.4–80% cases for unexplained bleeding, 61% for Crohn's disease [1].
The only reported complication is retention, reported in 0.75–3% of cases [2]. Patients with extensive small bowel Crohn's disease, chronic usage of non-steroidal anti-inflammatory drugs and abdominal radiation injury are at higher risk.
Capsule endoscopy is contraindicated in patients with known strictures or swallowing disorders.
A video-capsule impaction at the cricopharyngeus has been previously described [8].
Aspiration has been reported previously in only five cases. In three cases, the patients described difficulties in swallowing the capsule with cough, throat pain and sensation of a foreign body. In three cases [5–7] the capsule was expulsed by the cough and the aspiration was proved by the images obtained by the capsule, showing the trachea in one case and the right lower lobe bronchus in one case. The capsule was subsequently swallowed and examination of the GI tract could be performed.
In the other case, the diagnosis was obtained by the images of the capsule and CT-scan. The capsule had to be removed using rigid bronchoscopy [3].
Our report is the first case of asymptomatic capsule endoscopy aspiration; the capsule was swallowed in front of the gastroenterologist without any problem and the patient did not report any symptoms during the time the capsule was located in the respiratory tree. We hypothesized that the previous stroke was responsible for this asymptomatic aspiration.
Schiff et al. [4] gave some recommendations to helping prevent capsule aspiration and to make an early diagnosis of this complication: - Patients with swallowing disorders should have the capsule placed into the duodenum at the time of upper endoscopy. The capsule should never be placed in the stomach because of prolonged emptying times following endoscopy and IV sedation.
- If a patient appears to have difficulty swallowing the capsule after two or three attempts, the capsule should be placed endoscopically.
- When real-time capsule location is more readily available, the abdomen can be scanned after the initial ingestion to be sure that the capsule reached the stomach.
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4. Conclusion
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Aspiration of the video capsule can be observed without symptoms. Recommendations can be used to prevent this complication. Rigid bronchoscopy is safe to treat this complication.
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References
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Abstract
1. Introduction
