Prolonged Asymptomatic Tracheal Aspiration of a Small Bowel Capsule Endoscope

ABSTRACT

Aspiration into the respiratory tract is a rare complication of capsule endoscopy. We describe a patient whose small bowel capsule endoscopy was complicated by aspiration into the proximal trachea without apparent respiratory symptoms. Spontaneous expulsion of the capsule device through coughing occurred approximately 10 hours later.

INTRODUCTION

Small bowel capsule endoscopy is an essential tool for assessing portions of the small bowel that are not readily accessible by upper gastrointestinal (GI) endoscopy or colonoscopy. Aspiration of the capsule endoscopy into the respiratory tract is a rare complication.¹ We present a patient who experienced accidental capsule aspiration into the trachea with spontaneous expulsion from the respiratory tract approximately 10 hours later.

CASE REPORT

A 91-year-old man with pertinent history of atrial fibrillation, anticoagulated with rivaroxaban, presented with massive bleeding from the upper GI tract. During initial enteroscopy, a jejunal diverticulum was identified as the source of the bleeding, and hemostasis was achieved with a hemoclip placement. A few days later, he developed recurrent overt GI bleeding, and so, bidirectional endoscopy with enteroscopy and colonoscopy was pursued. The previous jejunal diverticulum was visualized without evidence of recent bleeding, and no other source of bleeding was identified on either procedure. To determine the source of the recurrent bleeding, small bowel capsule endoscopy was performed during the same hospital admission. The patient swallowed the capsule device (PillCam Small Bowel 3 Capsule; Medtronic, Minneapolis, MN) while seated in an upright position without any apparent difficulty. The video recording of the study revealed that the capsule was swallowed into the proximal trachea; the right and left primary bronchi were not visualized (Figure 1). After ingestion, the patient did not display any symptoms or evidence of respiratory compromise. The capsule was coughed up by the patient approximately 10 hours later. Upper device-assisted enteroscopy was subsequently performed without identification of the bleeding source, and the patient did not have further episodes of GI bleeding during the hospitalization. After discussion of the risks and benefits of anticoagulation, his rivaroxaban remained held upon discharge home, and outpatient follow-up was scheduled with his primary care physician and cardiologist.

Figure 1.

Representative image from the patient's small bowel capsule endoscopy video demonstrating aspiration of the capsule endoscope proximal to the bifurcation of the trachea.

DISCUSSION

Small bowel capsule endoscopy is a powerful diagnostic modality that allows for visualization of the entire small bowel. Common indications include overt and occult obscure GI bleeding, iron deficiency anemia, and for diagnosis and assessment of small bowel Crohn's disease. A well-known complication is retention of the capsule endoscopy within the small bowel, and so, testing with a patency capsule is recommended in patients with risk factors, including known stenosis and a history of small bowel obstruction or surgeries. Accidental aspiration into the respiratory tract is a rare but increasingly recognized potential complication of capsule endoscopy. To minimize the risk of aspiration, ingestion of the capsule endoscopy should be performed in a standing or upright seated position rather than lying down. Regardless, endoscopic placement should be considered in patients with risk factors for aspiration, including elderly age and the presence of swallowing or neurological disorders. However, this does not completely obviate the risk of aspiration as regurgitation of the capsule endoscopy is still possible, even with postpyloric placement.² In the absence of spontaneous expulsion, bronchoscopy is often required for retrieval.³ Respiratory distress may occur if the capsule endoscopy becomes lodged in a main stem bronchus.⁴ Fortunately, our patient did not experience significant respiratory symptoms after accidental aspiration of the capsule endoscope into the trachea proximal to the carina. This is highly unusual as often the capsule endoscope spontaneously will return to the GI tract without causing symptoms.³ To the best of our knowledge, this is the first description of an asymptomatic tracheal aspiration of capsule endoscope with self-expulsion from the respiratory tract via coughing after a significant amount of time.

DISCLOSURES

Author contributions: J. Travers: contribution to concept and drafting work and is the article guarantor. G. Isenberg: contribution to concept and final approval.

Financial disclosure: None to report.

Informed consent was obtained for this case report.