2017-07-26 20:19:59 UTC

“Errare Humanum Est, Perseverare Autem Diabolicum”

July 26, 2017

What caused two capsule recordings inside a 79-year-old man to stop recording after only 20 minutes?

Gastroenterology Clinical Image Challenge: A 79-year-old man with no significant past medical history presented to the emergency department with a two-day history of melena. He was hemodynamically stable and laboratory tests were unremarkable, except for normocytic anemia (hemoglobin, 9.1 g/dL; mean corpuscular volume, 82 fl; ferritin, 38 ng/mL). He reported a seven-day history of therapy with ibuprofen 200 mg twice a day for persistent lumbago.

The patient underwent gastroscopy with a negative result. A colonoscopy performed the day after was also negative. He was therefore referred for an outpatient capsule endoscopy, which was performed a week later (Mirocam, Intromedic Inc., Seoul Korea). He swallowed the capsule smoothly without real-time monitoring.

The patient brought the recorder back the following day; he referred that the recorder light stopped blinking approximately 30 minutes after ingestion. The capsule recording was a 25-minute video showing normal esophageal mucosa, with a very slow capsule progression (Figure A). The short recording time was interpreted as a possible system malfunction. The patient was asymptomatic, but he was unable to report capsule excretion; therefore, six days later an abdominal radiograph was performed, as per protocol in our center. No radiopaque object was identified and a new capsule endoscopy was scheduled.

The second capsule ingestion was performed under Wi-Fi real time monitoring (Miroview RTV application; Mirocam, Intromedic Inc.). As with the previous examination, the capsule showed normal esophageal mucosa without any obvious lumen; moreover, a nonblinking capsule was clearly identified (Figure B) in several frames five minutes after ingestion. 20 minutes later, the recording suddenly stopped. A plain neck and chest radiograph was performed. It showed two radiopaque foreign bodies, compatible with capsules, retained in the patient’s neck (Figure C).

What is the diagnosis?

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