Iatrogenic intestinal obstruction: a rare complication of capsule endoscopy in a patient with familial adenomatous polyposis

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in familial adenomatous polyposis syndromes

Familial adenomatous polyposis (FAP) syndrome is a complex entity, which includes FAP, attenuated FAP, and MUTYH-associated polyposis. These patients are at significant risk for colorectal cancer and carry additional risks for extracolonic malignancies. In this guideline, we reviewed the most recent literature to formulate recommendations on the role of endoscopy in this patient population. Relevant clinical questions were how to identify high-risk individuals warranting genetic testing, when to start screening examinations, what are appropriate surveillance intervals, how to identify endoscopically high-risk features, and what is the role of chemoprevention. A systematic literature search from 2005 to 2018 was performed, in addition to the inclusion of seminal historical studies. Most studies were from worldwide registries, which have compiled years of data regarding the natural history and cancer risks in this cohort. Given that most studies were retrospective, recommendations were based on epidemiologic data and expert opinion. Management of colorectal polyps in FAP has not changed much in recent years, as colectomy in FAP is the standard of care. What is new, however, is the developing body of literature on the role of endoscopy in managing upper GI and small-bowel polyposis, as patients are living longer and improved endoscopic technologies have emerged.

Endoscopic approach to capsule endoscope retention

In recent years, wireless capsule endoscopy has become increasingly indicated and utilized in the diagnosis and management of small bowel disorders. As such, its most common complication, capsule retention, has become a more frequently encountered clinical entity. Historically, when medical management of capsule retention has failed, patients have been sent directly to surgery. However, recent advances in small bowel enteroscopy have demonstrated a high success rate and safety profile in retrieving retained capsules. These approaches appear to be a viable alternative to surgery in many clinical scenarios. This article discusses both standard and advanced endoscopic approaches to capsule retention, and presents an algorithmic approach to their utilization.

Capsule retention: a feared complication of wireless capsule endoscopy

Wireless capsule endoscopy is a simple, non-invasive technique for the visualization of the entire small bowel. It was introduced in clinical praxis in 2001 and has already become the method of choice for the investigation of small-bowel pathology. Capsule retention is a major complication, with an overall incidence of 1-2%, although reported rates vary widely from 0% to 21%, depending on the indication for the examination. This complication can occur at any level of the gastrointestinal tract and in most cases runs asymptomatically. However, symptomatic bowel obstruction requiring surgical or endoscopic removal of the impacted capsule can occur. Rarely, capsule retention can lead to intestinal perforation. Despite several years of experience with wireless capsule endoscopy, there is up to the present no safe means of predicting capsule retention. Radiological studies have a low diagnostic yield and tend to underestimate or overestimate small-bowel strictures. The role of the new generation patency capsule (Agile patency capsule) needs to be further documented. The experts agree that obtaining a careful history is perhaps the best single method to detect the possibility of retention.