A man in his 50s was referred for evaluation of diarrhea. He had had diarrhea since he was a teenager. He had tested positive for fecal occult blood and undergone colonoscopy 12 years ago. Colonoscopy revealed multiple aphthae at that time. He was prescribed mesalazine; however, follow-up colonoscopy a year later revealed no difference in the aphthae, and he subsequently discontinued therapy. Recently, his diarrhea increased in frequency and he lost a total of 4 kg of body weight. Physical examination performed by his family doctor revealed the patient to have tenderness in the left upper quadrant of the abdomen; however, there were no palpable masses. Upper gastrointestinal endoscopy and ileocolonoscopy showed a normal appearance. Laboratory examination was normal. Additionally, abdominal computed tomography was negative for masses and bowel dilatation. Capsule endoscopy (CE) was performed to evaluate the small intestine, which revealed longitudinal ulcers and fold convergences (Fig 14.2a). Ninety minutes after swallow, the real-time viewer revealed food residues and stenosis in the upper jejunum (Fig 14.2b). Capsule retention then occurred. Four weeks later, the patient underwent anterograde single-balloon endoscopy. There were no lesions in the esophagus, stomach, and duodenum; however, there were several longitudinal ulcers and pseudodiverticular formations in the upper jejunum (Fig 14.3a). The retained capsule was found in a stenotic area 70 cm from the pylorus (Fig 14.3b, c). The capsule was retrieved and the stenosis was dilated using a through-the-scope (TTS) balloon. After diagnosis, the patient was treated with an anti-TNF antibody.

Diagnostic delay is frequent in patients with CD [4]. In this case, the diagnosis took more than 10 years. Small intestinal lesions often cause minimal or no symptoms. Some cases are not diagnosed until the presence of severe stenosis or fistula is discovered. Ileocolonoscopy is an important tool for the diagnosis and assessment of CD [5]. Most of the cases are associated with colonic or ileal lesions; however, a few cases have only jejunal lesions. Patients with lesions in the ileum are more likely to have a stricturing behavior [6]. In the present case, CD was diagnosed in part by retention of the capsule used in CE. Capsule retention is not only an adverse event but also an important finding [7]. However, CE should be removed if it is retained in the body. Retained capsules are contraindications for magnetic resonance imaging studies. Balloon-assisted endoscopy (BAE) is a good procedure for the retrieval of retained capsules [8]; however, adhesions that are common in the patients with CD often make BAE difficult. Recently, the patency capsule has been developed and this helps avoid retention [9].

A patient in her 20s complained of severe diarrhea and weight loss. Colonoscopy revealed typical longitudinal ulcers and a cobblestone appearance of the ascending colon (Fig. 14.4). She was diagnosed with CD and treated with an anti-TNF-alpha antibody. Mucosal healing occurred; however, she developed stenosis of the ileocecal valve (Fig. 14.5). The obstruction did not resolve despite repeated endoscopic balloon dilation. Eventually, the patient underwent an ileocecal resection. She remained asymptomatic for 6 months; however, she developed obstructive symptoms of abdominal distention and vomiting and was hospitalized. Single-balloon enteroscopy revealed no evidence of stenosis at the anastomosis (Fig 14.6a); however, membranous stenosis without ulceration was discovered in the middle ileum (Fig 14.6b, c). This was treated by balloon dilation using a 15-mm TTS balloon (Fig 14.6d). After dilation, the obstructive symptoms resolved (Fig 14.6e). As per the patient’s history, she often treated her headaches with ibuprofen. After counseling her to stop taking NSAIDs, the obstructive symptoms have not returned. It was determined that NSAIDs caused enteropathy and stenosis.