Case Presentation: A 57-year-old male with rheumatoid arthritis on methotrexate, hydroxychloroquine, and etodolac (NSAID) presented to the emergency room with acute abdominal pain, nausea, and vomiting. Three months prior, the patient had multiple episodes of severe abdominal pain. Colonoscopy and esophagogastroduodenography (EGD) demonstrated gastritis only. Six weeks prior, his gastroenterologist proceeded with video capsule endoscopy (VCE) for the suspicion of Crohn’s disease, which revealed multiple small bowel ulcerations but failed to pass due to multifocal ileal narrowing. A Medrol dose pack trial was ineffective. On presentation, the workup revealed mild leukocytosis (WBC 11,800 /uL) and CRP of 8.5 mg/L. CT imaging demonstrated partial small bowel obstruction associated with a distal ileal stricture proximal to the retained VCE, with additional areas of lesser luminal narrowing in the small bowel. The multidisciplinary team (gastroenterology and colorectal surgery) elected to pursue a trial of corticosteroid treatment with intravenous methylprednisolone 40 mg daily for three days, followed by oral prednisone 40 mg daily. The patient clinically improved rapidly, resuming stool passage and tolerating a low-residue diet. Follow-up CT enterography showed decreased inflammation and improved bowel patency, though the retained VCE remained in the distal small bowel due to the residual stricture. One week after discharge, the patient underwent the planned exploratory laparotomy for diagnostic purposes and VCE removal; however, the VCE had already passed. Following clinical improvement with steroids, and with subsequent supportive endoscopic findings, the patient was diagnosed with Crohn’s disease and initiated on adalimumab.
Discussion: Although generally safe, approximately 5.8% of patients who undergo VCE face complications, with capsule retention being the most notable. Retention of VCE is defined as the presence of the capsule endoscope in the digestive tract for a minimum of 2 weeks and occurs more frequently in patients with known or suspected stricturing disease. While often asymptomatic, capsule retention can lead to acute bowel obstruction as was in our case. In cases of suspected strictures, radiologic testing in conjunction with a patency capsule has been found helpful in minimizing the risk of retention. Management strategies for retained VCE range from conservative observation to medical treatment with corticosteroids or biologics, with surgical intervention reserved for patients with obstruction, bleeding, or other complications. This case illustrates an important clinical decision point between a reversible inflammatory stricture and other fibrotic strictures. In our patient, the successful corticosteroid therapy not only treated the bowel obstruction but also suggested that the main cause was the reversible inflammatory process from underlying Crohn’s disease rather than fibrotic strictures from the long-term NSAID use. This approach also allowed the spontaneous passage of the retained VCE.
Conclusions: Retained VCE presenting with small bowel obstruction warrants a multidisciplinary approach. When an ileal disease is suspected, a trial of corticosteroids can be therapeutic and diagnostic to uncover underlying inflammatory processes and allow spontaneous VCE passage. To avoid this complication, a patency capsule or CT enterography should be considered when strictures are anticipated.