Case Report
Sonographic Detection of a Patency Capsule Prior to Capsule Endoscopy: Case Report Yuka Kobayashi, MD, PhD, Atsuo Yamada, MD, PhD, Hirotsugu Watabe, MD, PhD, Ryota Takahashi, MD, PhD, Hirobumi Suzuki, MD, Yoshihiro Hirata, MD, PhD, Yutaka Yamaji, MD, PhD, Haruhiko Yoshida, MD, PhD, Kazuhiko Koike, MD, PhD Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan Received 6 February 2013; accepted 18 February 2014
ABSTRACT: To avoid retention of the capsule used in capsule endoscopy (CE), the patency capsule (PC), a self-disintegrating sham capsule, is administered prior to CE in patients suspected of small intestinal stenosis. If the PC is excreted intact within 30 hours of ingestion, the patient can undergo CE without retention. However, if the PC is not excreted within 30 hours, its location must be confirmed as in either the small intestine or the colon because of the potential for small intestinal stenosis in the former case. It is often difficult to confirm the location of the PC by abdominal radiograph. We report the case of one patient who did not excrete the PC within 30 hours and for whom it was difficult to distinguish whether the PC was in the small intestine or the colon on abdominal series. Abdominal sonography revealed the PC in the colon and subsequent CE was perC 2014 Wiley Periodiformed without complication. V cals, Inc. J Clin Ultrasound 42:554–556, 2014; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22147 Keywords: patency capsule; ultrasonography; capsule endoscopy; abdomen; gastrointestinal tract
C
apsule endoscopy (CE) has become an important examination of the small intestine.1 The most common complication of CE is capsule retention. Capsule retention is defined as the presence of the capsule in the small intestine for a minimum of 2 weeks after ingestion. The most common cause of capsule retention is stenosis of the small intestine, such as Crohn’s disease, nonsteroidal anti-inflammatory
Correspondence to: A. Yamada C 2014 Wiley Periodicals, Inc. V
554
drug enteropathy, or previous abdominal surgery.2,3 The patency capsule (PC) (Agile Patency Capsule; Given Imaging, Yoqneam, Israel) is a new device for the detection of patients with risk of capsule retention.4 The PC is a selfdisintegrating sham capsule and equal in size and shape to that used in CE. The PC is composed of a lactose body with 5% barium that surrounds a small radiofrequency identification tag. Its body is coated with an impermeable membrane, except for two small areas containing a timer plug located at each end of the capsule. Each timer plug is opened by contact with the gastrointestinal fluids. If the capsule is retained in the small intestine, the timer plug erodes after 30 hours, allowing the subsequent dissolution in the body. The remaining fragments of the capsule can pass even tight strictures. In Japan, the Agile-J PC (Given Imaging) has been available since July 2012. The Agile-J PC has the same shape and size as the PC. The only difference is that the Agile-J PC does not contain a radiofrequency identification tag. When the PC is excreted intact, the patient can undergo CE without retention.4,5 If there is stenosis in the small intestine, the PC remains in the small intestine and subsequently disintegrates. If the PC is not excreted within 30 hours of ingestion, its location must be confirmed as in either the small intestine or the colon. Radiologic examinations such as abdominal radiograph or CT are usually performed to confirm the location of the PC. However, it is occasionally difficult to confirm the location of the PC by abdominal radiographs. Moreover, sonography (US) is able to JOURNAL OF CLINICAL ULTRASOUND
ULTRASONOGRAPHY FOR PATENCY CAPSULE DETECTION
FIGURE 1. Contrast-enhanced CT scan shows diffuse wall thickness on the lower side of the small intestine.
FIGURE 3. Abdominal radiograph shows that the PC was on the upper right side of the abdomen in the supine position.
FIGURE 2. Retrograde double-balloon enteroscopy shows villous atrophy or deficit and skinned mucosa was present in part of the small intestine.
distinguish the small intestine from the colon. The small intestine has circular folds of Kerckring, while the colon has haustra—large bulges between the colic teniae. The presence of gas also indicates that the lumen being observed is the colon and not the small intestine. We report a case in which abdominal US was useful for the detection of the PC in the colon.
CASE REPORT
A 73-year-old man was admitted to our hospital because of intermittent abdominal pain. His white cell count was 8,300/ll (normal range 3,500–9,200) and C-reactive protein level was 8.57 mg/dl (normal range 0.00–0.03). EsophagoVOL. 42, NO. 9, NOVEMBER/DECEMBER 2014
gastroduodenoscopy and colonoscopy showed no significant findings. Abdominal contrastenhanced CT examination revealed diffuse wall thickening of the ileum (Figure 1). We performed CE and found multiple ulcers and diffuse atrophic villi on the lower side of the small intestine. Retrograde double-balloon enteroscopy (DBE) was performed to investigate the small intestinal ulcers detected by CE. DBE showed various forms of multiple ulcers; some were circular and circumferential, and others were longitudinal or irregular. DBE also showed villous atrophy or deficit and skinned mucosa was seen in part of the small intestine (Figure 2). Biopsy revealed nonspecific inflammation of the small intestine. The patient was treated with intestinal rest and total parenteral nutrition. After 1 month, his abdominal pain was relieved. We planned to reassess the small intestinal lesions by CE. We considered the possibility of CE retention due to the stenosis that can occasionally develop during the healing process. We then administered the PC. Thirty hours after ingestion, the PC had not been excreted. Abdominal radiographs showed the PC in the right upper quadrant of the abdomen (Figure 3). In this case, it was difficult to confirm that the PC was in the colon and not the small intestine. Therefore, we performed an abdominal US immediately after the abdominal series. Abdominal US was performed with an APLIO XG scanner (Toshiba Medical Systems, Tokyo, Japan) and a PVT-375BT convex 555
KOBAYASHI ET AL
performed an abdominal US, which allowed detection of the PC and revealed its location within 5 minutes. The usefulness of abdominal US for the detection of a foreign body or tumor in the intestine has been reported.8,9 Ido et al. reported that US was capable of revealing anisakiasis in the small intestine.10 Our findings indicate that US is capable of detecting a PC, which was visible as a hyperechoic object. We also confirmed that the PC retained its intact shape. However, abdominal US has some disadvantages. US visibility depends on the patient’s condition in terms of intestinal gas, obesity, and history of abdominal surgery. Alternative modalities, including abdominal CT scan or MRI, may be used in such cases.
REFERENCES
FIGURE 4. Abdominal ultrasonography shows that the PC was located on the right side of the colon and was intact. (A) Longitudinal view; (B) Transverse view.
transducer (2.8–4.2 MHz). Abdominal US detected a hyperechoic object with an acoustic shadow (Figure 4). The dimensions of the object were identical to those of the PC, indicating that the object was the PC. Abdominal US showed that the outline was intact. Moreover, US showed that the PC was located in the intestinal lumen with haustra representing the colon. The abdominal US examination time was 5 minutes. We confirmed the absence of stenosis in the small intestine. The PC was excreted eventually. Finally, the patient underwent CE sequentially without retention. CE showed multiple ulcers in the small intestine that were in the process of healing.
DISCUSSION
CE is the least invasive endoscopic method. The only risk is capsule retention, the probability of which is 1.2–2.6%.3,6 However, the risk of capsule retention in patients with Crohn’s disease is 13%.7 To reduce the probability of retention, a PC is commonly used. Confirmation of PC excretion into the colon requires abdominal radiograph and/or CT scan. In our case, we
556
1. Iddan G, Meron G, Glukhovsky A, et al. Wireless capsule endoscopy. Nature 2000;405:417. 2. Cave D, Legnani P, de Franchis R, et al. ICCE consensus for capsule retention. Endoscopy 2005;37: 1065. 3. Liao Z, Gao R, Xu C, et al. Indications and detection, completion, and retention rates of smallbowel capsule endoscopy: a systematic review. Gastrointest Endosc 2010;71:280. 4. Herrerias JM, Leighton JA, Costamagna G, et al. Agile patency system eliminates risk of capsule retention in patients with known intestinal strictures who undergo capsule endoscopy. Gastrointest Endosc 2008;67:902. 5. Yadav A, Heigh RI, Hara AK, et al. Performance of the patency capsule compared with nonenteroclysis radiologic examinations in patients with known or suspected intestinal strictures. Gastrointest Endosc 2011;74:834. 6. Li F, Gurudu SR, De Petris G, et al. Retention of the capsule endoscope: a single-center experience of 1000 capsule endoscopy procedures. Gastrointest Endosc 2008;68:174. 7. Cheifetz AS, Kornbluth AA, Legnani P, et al. The risk of retention of the capsule endoscope in patients with known or suspected Crohn’s disease. Am J Gastroenterol 2006;101:2218. 8. Parra DA, Navarro OM. Sonographic diagnosis of intestinal polyps in children. Pediatr Radiol 2008; 38:680. 9. Ripolles T, Garcıa-Aguayo J, Martınez MJ, et al. Gastrointestinal bezoars: sonographic and CT characteristics. AJR Am J Roentgenol 2001;177:65. 10. Ido K, Yuasa H, Ide M, et al. Sonographic diagnosis of small intestinal anisakiasis. J Clin Ultrasound 1998;26:125.
JOURNAL OF CLINICAL ULTRASOUND
Sonographic Detection of a Patency Capsule Prior to Capsule Endoscopy: Case Report Yuka Kobayashi, MD, PhD, Atsuo Yamada, MD, PhD, Hirotsugu Watabe, MD, PhD, Ryota Takahashi, MD, PhD, Hirobumi Suzuki, MD, Yoshihiro Hirata, MD, PhD, Yutaka Yamaji, MD, PhD, Haruhiko Yoshida, MD, PhD, Kazuhiko Koike, MD, PhD Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan Received 6 February 2013; accepted 18 February 2014
ABSTRACT: To avoid retention of the capsule used in capsule endoscopy (CE), the patency capsule (PC), a self-disintegrating sham capsule, is administered prior to CE in patients suspected of small intestinal stenosis. If the PC is excreted intact within 30 hours of ingestion, the patient can undergo CE without retention. However, if the PC is not excreted within 30 hours, its location must be confirmed as in either the small intestine or the colon because of the potential for small intestinal stenosis in the former case. It is often difficult to confirm the location of the PC by abdominal radiograph. We report the case of one patient who did not excrete the PC within 30 hours and for whom it was difficult to distinguish whether the PC was in the small intestine or the colon on abdominal series. Abdominal sonography revealed the PC in the colon and subsequent CE was perC 2014 Wiley Periodiformed without complication. V cals, Inc. J Clin Ultrasound 42:554–556, 2014; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22147 Keywords: patency capsule; ultrasonography; capsule endoscopy; abdomen; gastrointestinal tract
C
apsule endoscopy (CE) has become an important examination of the small intestine.1 The most common complication of CE is capsule retention. Capsule retention is defined as the presence of the capsule in the small intestine for a minimum of 2 weeks after ingestion. The most common cause of capsule retention is stenosis of the small intestine, such as Crohn’s disease, nonsteroidal anti-inflammatory
Correspondence to: A. Yamada C 2014 Wiley Periodicals, Inc. V
554
drug enteropathy, or previous abdominal surgery.2,3 The patency capsule (PC) (Agile Patency Capsule; Given Imaging, Yoqneam, Israel) is a new device for the detection of patients with risk of capsule retention.4 The PC is a selfdisintegrating sham capsule and equal in size and shape to that used in CE. The PC is composed of a lactose body with 5% barium that surrounds a small radiofrequency identification tag. Its body is coated with an impermeable membrane, except for two small areas containing a timer plug located at each end of the capsule. Each timer plug is opened by contact with the gastrointestinal fluids. If the capsule is retained in the small intestine, the timer plug erodes after 30 hours, allowing the subsequent dissolution in the body. The remaining fragments of the capsule can pass even tight strictures. In Japan, the Agile-J PC (Given Imaging) has been available since July 2012. The Agile-J PC has the same shape and size as the PC. The only difference is that the Agile-J PC does not contain a radiofrequency identification tag. When the PC is excreted intact, the patient can undergo CE without retention.4,5 If there is stenosis in the small intestine, the PC remains in the small intestine and subsequently disintegrates. If the PC is not excreted within 30 hours of ingestion, its location must be confirmed as in either the small intestine or the colon. Radiologic examinations such as abdominal radiograph or CT are usually performed to confirm the location of the PC. However, it is occasionally difficult to confirm the location of the PC by abdominal radiographs. Moreover, sonography (US) is able to JOURNAL OF CLINICAL ULTRASOUND
ULTRASONOGRAPHY FOR PATENCY CAPSULE DETECTION
FIGURE 1. Contrast-enhanced CT scan shows diffuse wall thickness on the lower side of the small intestine.
FIGURE 3. Abdominal radiograph shows that the PC was on the upper right side of the abdomen in the supine position.
FIGURE 2. Retrograde double-balloon enteroscopy shows villous atrophy or deficit and skinned mucosa was present in part of the small intestine.
distinguish the small intestine from the colon. The small intestine has circular folds of Kerckring, while the colon has haustra—large bulges between the colic teniae. The presence of gas also indicates that the lumen being observed is the colon and not the small intestine. We report a case in which abdominal US was useful for the detection of the PC in the colon.
CASE REPORT
A 73-year-old man was admitted to our hospital because of intermittent abdominal pain. His white cell count was 8,300/ll (normal range 3,500–9,200) and C-reactive protein level was 8.57 mg/dl (normal range 0.00–0.03). EsophagoVOL. 42, NO. 9, NOVEMBER/DECEMBER 2014
gastroduodenoscopy and colonoscopy showed no significant findings. Abdominal contrastenhanced CT examination revealed diffuse wall thickening of the ileum (Figure 1). We performed CE and found multiple ulcers and diffuse atrophic villi on the lower side of the small intestine. Retrograde double-balloon enteroscopy (DBE) was performed to investigate the small intestinal ulcers detected by CE. DBE showed various forms of multiple ulcers; some were circular and circumferential, and others were longitudinal or irregular. DBE also showed villous atrophy or deficit and skinned mucosa was seen in part of the small intestine (Figure 2). Biopsy revealed nonspecific inflammation of the small intestine. The patient was treated with intestinal rest and total parenteral nutrition. After 1 month, his abdominal pain was relieved. We planned to reassess the small intestinal lesions by CE. We considered the possibility of CE retention due to the stenosis that can occasionally develop during the healing process. We then administered the PC. Thirty hours after ingestion, the PC had not been excreted. Abdominal radiographs showed the PC in the right upper quadrant of the abdomen (Figure 3). In this case, it was difficult to confirm that the PC was in the colon and not the small intestine. Therefore, we performed an abdominal US immediately after the abdominal series. Abdominal US was performed with an APLIO XG scanner (Toshiba Medical Systems, Tokyo, Japan) and a PVT-375BT convex 555
KOBAYASHI ET AL
performed an abdominal US, which allowed detection of the PC and revealed its location within 5 minutes. The usefulness of abdominal US for the detection of a foreign body or tumor in the intestine has been reported.8,9 Ido et al. reported that US was capable of revealing anisakiasis in the small intestine.10 Our findings indicate that US is capable of detecting a PC, which was visible as a hyperechoic object. We also confirmed that the PC retained its intact shape. However, abdominal US has some disadvantages. US visibility depends on the patient’s condition in terms of intestinal gas, obesity, and history of abdominal surgery. Alternative modalities, including abdominal CT scan or MRI, may be used in such cases.
REFERENCES
FIGURE 4. Abdominal ultrasonography shows that the PC was located on the right side of the colon and was intact. (A) Longitudinal view; (B) Transverse view.
transducer (2.8–4.2 MHz). Abdominal US detected a hyperechoic object with an acoustic shadow (Figure 4). The dimensions of the object were identical to those of the PC, indicating that the object was the PC. Abdominal US showed that the outline was intact. Moreover, US showed that the PC was located in the intestinal lumen with haustra representing the colon. The abdominal US examination time was 5 minutes. We confirmed the absence of stenosis in the small intestine. The PC was excreted eventually. Finally, the patient underwent CE sequentially without retention. CE showed multiple ulcers in the small intestine that were in the process of healing.
DISCUSSION
CE is the least invasive endoscopic method. The only risk is capsule retention, the probability of which is 1.2–2.6%.3,6 However, the risk of capsule retention in patients with Crohn’s disease is 13%.7 To reduce the probability of retention, a PC is commonly used. Confirmation of PC excretion into the colon requires abdominal radiograph and/or CT scan. In our case, we
556
1. Iddan G, Meron G, Glukhovsky A, et al. Wireless capsule endoscopy. Nature 2000;405:417. 2. Cave D, Legnani P, de Franchis R, et al. ICCE consensus for capsule retention. Endoscopy 2005;37: 1065. 3. Liao Z, Gao R, Xu C, et al. Indications and detection, completion, and retention rates of smallbowel capsule endoscopy: a systematic review. Gastrointest Endosc 2010;71:280. 4. Herrerias JM, Leighton JA, Costamagna G, et al. Agile patency system eliminates risk of capsule retention in patients with known intestinal strictures who undergo capsule endoscopy. Gastrointest Endosc 2008;67:902. 5. Yadav A, Heigh RI, Hara AK, et al. Performance of the patency capsule compared with nonenteroclysis radiologic examinations in patients with known or suspected intestinal strictures. Gastrointest Endosc 2011;74:834. 6. Li F, Gurudu SR, De Petris G, et al. Retention of the capsule endoscope: a single-center experience of 1000 capsule endoscopy procedures. Gastrointest Endosc 2008;68:174. 7. Cheifetz AS, Kornbluth AA, Legnani P, et al. The risk of retention of the capsule endoscope in patients with known or suspected Crohn’s disease. Am J Gastroenterol 2006;101:2218. 8. Parra DA, Navarro OM. Sonographic diagnosis of intestinal polyps in children. Pediatr Radiol 2008; 38:680. 9. Ripolles T, Garcıa-Aguayo J, Martınez MJ, et al. Gastrointestinal bezoars: sonographic and CT characteristics. AJR Am J Roentgenol 2001;177:65. 10. Ido K, Yuasa H, Ide M, et al. Sonographic diagnosis of small intestinal anisakiasis. J Clin Ultrasound 1998;26:125.
JOURNAL OF CLINICAL ULTRASOUND
