Video Capsule Endoscopy: Think Pharyngeal Pouch – Retention of a Video Capsule in a 94-Year-Old in the Upper Gastrointestinal Tract
Article information
Abstract
Video capsule endoscopy (VCE) provides endoluminal visualisation of the small bowel. It is often regarded as well-tolerated, non-invasive, and safe across all age groups, with the main, albeit rare, complication of retention of the capsule, normally in the small bowel or lower gastrointestinal (GI) tract. Retention in the upper GI tract is extremely rare; here, we present a case of a 94-year-old who experienced capsule retention in a previously undiagnosed pharyngeal pouch. This appears to be the first case report detailing video capsule retention in a pharyngeal pouch involving a patient of such an advanced age, and in which endoscopic retrieval was not necessitated. The learning here is that patients should be evaluated for prior medical history or the possibility of a pharyngeal pouch before performing VCE.
INTRODUCTION
Video capsule endoscopy (VCE) is a non-invasive and well-tolerated investigative modality that provides endoluminal imaging of the small bowel.1) Common indications include investigation of unexplained gastrointestinal (GI) bleeding, unexplained iron deficiency anaemia, and evaluation for and monitoring of, Crohn’s disease.2) In the instances of the first and second indications, VCE normally follows diagnostically unyielding upper and lower GI tract endoscopies.3)
Retention of the video capsule is the main adverse event and generally occurs in the small bowel or lower GI tract, and is defined as failure of the capsule to pass through the GI tract after 2 weeks of ingestion.1) The incidence of this complication is reportedly low, occurring in only 1%–2% of cases; however, this figure can be as high as 4%–13% in patients with inflammatory bowel disease, in which they are more susceptible to stricture formation.4,5) Older age alone is not recognised as a risk factor.4)
Retention of the capsule in the upper GI tract is reportedly extremely rare. A 2023 literature review by Arzivian et al.1) noted that there are only a small handful of case reports describing capsule retention in the upper GI tract. Within these, all 12 of the described patients were older adults with a median age of 75.8 years. American and Canadian guidelines on VCE contraindications mention swallowing and motility disorders of the upper GI tract, but do not specifically reference the presence of a pharyngeal pouch.6,7)
We present here a unique case of a 94-year-old patient who had a video capsule become lodged in her upper GI tract, in an undiagnosed pharyngeal pouch, during an acute hospital admission with a GI bleed. The capsule migrated within 24 hours with conservative management.
CASE REPORT
A 94-year-old woman with a medical history of osteoporosis and transient ischaemic attack presented to our emergency department from a care home following a syncopal episode while on the commode. Of note, her carers had noted black coloured stools in the commode pan. Her medications included denosumab, aspirin and calcium-vitamin D supplements.
On examination in the emergency department, she was alert, and her vital signs included a blood pressure of 102/64 mmHg, pulse rate 97 per minute, respiratory rate 20 per minute, temperature 36.8°C, and pulse oximetry 97% (on room air). She had epigastric tenderness, and black coloured stools were observed in the emergency department.
Her blood results showed a haemoglobin level of 108 g/L, mean corpuscular volume 90 fL, white cell count 16×109/L, platelet count 257×109/L, urea 19.7 mmol/L, creatinine 68 μmol/L, and C-reactive protein 4 mg/L. Her iron studies confirmed deficiency with a serum iron of 5.20 μmol/L, ferritin 82.3 μg/L, saturation 12%, and transferrin 1.86 g/L. Her B12 was 488 ng/L and folate 9.31 μg/L. For reference, historic blood results showed a haemoglobin of 126 g/L and urea of 5.8 mmol/L. The diagnostic impression was that of a presumed upper GI tract bleed. Her Glasgow-Blatchford Bleeding Score was calculated to be 9, and her aspirin was held.
Though she did not initially require a transfusion of packed red blood cells, nor did she require any correction of clotting abnormalities, on the next day her haemoglobin dropped to 86, which prompted a 1-unit transfusion of packed red blood cells, raising her count to 95. It was observed that she had ongoing black stools on the ward. An oesophago-gastroduodenoscopy (OGD) was performed, which did not show a source of bleeding nor any fresh blood, though a large hiatus hernia and a possible pharyngeal pouch were commented on due to difficult intubation, but no food residue was observed.
Over the next 3 days, her haemoglobin decreased again from 95 to 78 g/L, at which point she was transfused with two further units of packed red blood cells, raising her haemoglobin to 101 g/L. Given her advanced age and frailty, a CT angiogram of the abdomen and pelvis was performed next. This did not reveal any active bleeding, nor pathology in relation to her presentation. She subsequently underwent a flexible sigmoidoscopy examination up to the splenic flexure, noting black watery stool coming down from her proximal colon (Fig. 1), following which a VCE was sought.
Flexible sigmoidoscopy examination at the splenic flexure, noting black watery stool coming down from the proximal colon.
Immediately after ingestion of the video capsule (PillCam SB3; length 26.2 mm × diameter 11.4 mm; Medtronic, Dublin, Ireland), she complained of discomfort in her throat and the sensation that the capsule had become stuck. After 40 minutes of repositioning measures and ingestion of water, an OGD was attempted under sedation to visualise and retrieve the retained capsule. This was unsuccessful due to difficult intubation and food residue in the pharyngeal pouch. The patient was then returned to the ward, during which a chest X-ray showed a radio-opaque structure consistent with the lodged capsule in the neck (Fig. 2). On the day before VCE ingestion, she was maintained on clear fluids following her evening meal and kept nil-by-mouth from midnight.
Chest X-ray demonstrating video capsule in the neck.
She was advised by the gastroenterologists to eat and drink without restriction, and by the next day, the sensation of the retained capsule in her throat had disappeared. A repeat chest X-ray no longer showed the radio-opaque structure. Her haemoglobin remained stable for several short days thereafter, along with the resolution of her melaena. The patient wished for no further investigation or extension of her in-patient admission and so was discharged back to her care home. Her aspirin was stopped permanently, and a definitive source for her bleeding was ultimately not identified. An out-patient abdominal X-ray performed 2 weeks later did not show evidence of the capsule in the remaining GI tract. In retrospect, there was no patient-reported history of dysphagia or regurgitation of ingested food and nor was there evidence of pharyngeal pouch on review of her prior medical notes.
Written informed consent has been obtained from the involved patient.
DISCUSSION
A pharyngeal pouch, or Zenker’s diverticulum, is a rare condition with an incidence of about 2 per 100,000 people per year.8) It is the commonest diverticulum in the upper GI tract.9) Anatomically, these are located on the posterior pharyngeal wall within the upper oesophageal sphincter between the lower pharynx and oesophagus.8,10) They are commonly less than 4 cm, with less than 2 cm regarded as small, 2–4 cm regarded as medium, and more than 4 cm regarded as large.11) Their occurrence involves a chronic weakening of the oesophageal wall combined with repeated increases in luminal pressure associated with oral intake.12) It therefore commonly affects older adults, usually occurring in the 7th to 9th decades of life.13) Patients with this condition commonly describe regurgitation of ingested food.12)
In the previously mentioned literature review by Arzivian et al.,1) they had identified only 12 case reports in the literature in which retention of the video capsule occurred in the upper GI tract and all involving older adults. In 10 of these 12 cases, the site of the video capsule becoming lodged was in the pharyngeal pouch. A unique point, though in our patient is that she had spontaneous resolution of the lodged video capsule with continued normal oral intake within 24 hours. In all 12 of these cases, endoscopic capsule retrieval was required, and in the 3 in which this failed, they underwent rigid endoscopy under general anaesthesia. The authors of this review do conclude that the presence of a pharyngeal pouch should be viewed as a relative contraindication to VCE, despite it not being formally recognised as such. Simmons and Barron14) make a similar recommendation, arguing that video capsules measure on average 11 mm by 26 mm, and so patients with known pharyngeal pouches measuring greater than 30 mm should either not undergo the investigation or be well counselled on the risk. More positively, success has been reported in the literature in direct endoscopic delivery of the video capsule into the stomach in such patients as a workaround.15) As demonstrated in our patient, in the event of suspected capsule retention, a plain X-ray is considered first-line, given they are readily available and inexpensive to perform.4)
The diagnostic yield of video capsule endoscopy has been reported as high as 73%, 71% and 45% for "obscure gastrointestinal bleeding," "suspected small bowel Crohn’s disease," and "unexplained iron deficiency anaemia," respectively.16) A retrospective study of 499 older patients by Thurm et al.17) found that video capsule endoscopy in octa-nonagenerians is as safe as in younger older adults (above the age of 65 years), and in fact benefited from an even higher diagnostic yield of significant and treatable conditions, including active bleeding, angioectasia, and Crohn’s disease. Indeed, a negative study is often as useful as a positive one: Yung et al.18) found that in video capsule endoscopies performed for suspected bleeding, a negative study reassuringly predicted a much lower rate of re-bleeding.
In conclusion, pharyngeal pouches are not specifically recognised as a contraindication to VCE. The learning here is that evaluation for symptoms to suggest an undiagnosed pharyngeal pouch, and/or review of prior investigations for evidence of a pouch and its size, should be performed and serve as alerts towards enhanced patient counselling or alternative investigative modalities—particularly pouches of more than 3 cm in size of which is larger than most video capsules. If pouch retention does occur, this case report should serve to illustrate that conservative measures may lead to spontaneous migration of the capsule.
Notes
We thank the patient for their consent in allowing us to produce this case report.
CONFLICT OF INTEREST
The researchers claim no conflicts of interest.
FUNDING
None.
AUTHOR CONTRIBUTIONS
Conceptualization, WT, RC; Investigation, WT, RC; Writing_original draft, WT, RC; Writing_review & editing, WT, RC.