|Year : 2014 | Volume
| Issue : 2 | Page : 113-115
Silent bowel perforation with per anal protrusion of ventriculoperitoneal shunt
Sarvpreet Singh Grewal1, Sukhdeep Singh Jhawar1, Bharat Gupta1, Nandini K Bedi2
1 Department of Neurosurgery, Christian Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Paediatrics, Christian Medical College and Hospital, Ludhiana, Punjab, India
|Date of Web Publication||11-Jun-2014|
Sukhdeep Singh Jhawar
Department of Neurosurgery, Christian Medical College and Hospital, Ludhiana 141 008, Punjab
Source of Support: None, Conflict of Interest: None
Ventriculoperitoneal (VP) shunt used in the treatment for hydrocephalus is associated with several complications. Visceral/bowel perforation is an unusual but serious complication of VP shunt. A silent protrusion of distal end of VP shunt per anus is reported in an 8-month-old male child. Patient underwent right VP shunt at the age of 6 months for congenital hydrocephalous. Patient was afebrile and had no signs of peritonitis or meningitis. Exploratory laparotomy was done where shunt was found to penetrate antimesenteric border of sigmoid colon. Shunt was removed and patient is doing well at 6 months follow-up without revision of VP shunt. Etiopathogenesis and management issues are discussed with relevant review of literature.
Keywords: Hydrocephalous, per anus, sigmoid colon, ventriculoperitoneal shunt
|How to cite this article:|
Grewal SS, Jhawar SS, Gupta B, Bedi NK. Silent bowel perforation with per anal protrusion of ventriculoperitoneal shunt. CHRISMED J Health Res 2014;1:113-5
|How to cite this URL:|
Grewal SS, Jhawar SS, Gupta B, Bedi NK. Silent bowel perforation with per anal protrusion of ventriculoperitoneal shunt. CHRISMED J Health Res [serial online] 2014 [cited 2017 Mar 27];1:113-5. Available from: http://www.cjhr.org/text.asp?2014/1/2/113/134278
| Introduction|| |
Since introduction of ventriculoperitoneal (VP) shunt by Kausch for treatment of congenital hydrocephalous in 1905, it has become the most common operation done for management of hydrocephalous.  But it is also one of the surgical procedures associated with high complication rate. , Common complications include mechanical blockage of shunt, infection, cerebrospinal fluid (CSF) pseudocyst, CSF ascites, and peritonitis. Risk of abdominal complication associated with VP shunt is 25% and incidence of bowel perforation with protrusion of VP shunt from anus is 0.1-0.7%. , Many have peritonitis and it is fatal in up to 27% of cases. , But few patients can be asymptomatic, afebrile, and without peritonitis or meningitis as seen in present report.
| Case Report|| |
An 8-month-old male child, diagnosed as having congenital hydrocephalous, underwent right-sided VP shunt at age of 6 months. Now he presented with complaint of protrusion of distal part of shunt per anus. There was no history of fever, loss of appetite, vomiting, and abdominal distension. On examination, patient was afebrile with no signs of meningitis. There was no abdominal distension, tenderness, rigidity, or guarding and bowel sounds were present. Distal end of VP shunt was coming out per anus with dribbling of clear CSF [Figure 1]. CSF culture from distal end of catheter grew Klebsiella and was sensitive to amikacin and ceftriaxone. A plain X-ray of abdomen erect and supine showed no air under diaphragm. A computerized tomography (CT) of abdomen revealed distal end of VP shunt passing through colon and coming out of the anus [Figure 2] and [Figure 3].
|Figure 1: Distal end of ventriculoperitoneal shunt coming out per-anus and clear cerebrospinal fl uid dribbling from it|
Click here to view
|Figure 2: Scout fi lm of plain computerized tomographic scan of abdomen showing distal end of entriculoperitoneal shunt coming from anus|
Click here to view
|Figure 3: Axial plain computerized tomographic scan of abdomen showing distal end of ventriculoperitoneal shunt coming out from the anus|
Click here to view
The patient was optimized and then taken up for exploratory laparotomy. Intraoperatively, no free fluid was present. Distal part of VP shunt was seen piercing through antimesenteric border of sigmoid colon. The shunt was cut at entry point of antimesenteric border of sigmoid colon and distal part was taken out per anus. Proximal part of body of shunt was cut at entry point into peritoneal cavity. Separate scalp incision was given over previous scar to remove the chamber and ventricular part of VP shunt. Postoperative period was uneventful. There was no neurological deficit or increase in head circumference during hospital stay. The patient was discharged and advised to be on regular follow-up. At 6-month follow up, patient is asymptomatic and doing well without revision of VP shunt.
| Discussion|| |
Hydrocephalous is a common clinical entity dealt in neurosurgical practice. It is caused by imbalance between secretion and absorption of CSF or obstruction in CSF circulation. Most common procedure done for obstructive hydrocephalous is VP shunt. Other CSF diversion procedures are ventriculoatrial shunt (VA), lumboperitoneal shunt, choroid plexus coagulation, and third ventriculostomy. VP shunt is associated with complication rate of 24-47%, of which mechanical blockage of shunt is most common.  Visceral perforation is a rare, but serious complication of VP shunt with mortality rate up to 15%. Bowel is most common site of perforation, but nonenteric viscus perforations and protrusion of shunt from different sites has been described in literature. 
The average interval between perforations of viscera after putting VP shunt is between 2 and 20 months. In present case, the interval was 2 months. These patients are mostly afebrile and asymptomatic, but may present with gastroenteritis, signs of peritonitis or meningitis. Our patient was completely asymptomatic and was accepting well orally. Medium pressure and low pressure shunts used for treatment of congenital hydrocephalous has been found to have similar complication rates.  Literature has evidence that length of peritoneal part of shunt is not associated with increase in incidence of complications.  Ghritlaharey et al., reported 10 patients having protrusion of shunt through anus and described the sharpness at tip of peritoneal catheter as initiation factor for bowel perforation. Other contributing factors for perforation of bowel are infection and increased protein content in CSF. 
The probable explanation for asymptomatic bowel perforation is a chronic process of perforation of bowel that was surrounded by fibrous encasement at enterostomy site without subsequent peritonitis. After perforation of bowel, catheter is propelled distally by effect of intestinal peristalsis. Possible cause of perforation of sigmoid colon in our patient may be the effect of gravity, by which the peritoneal catheter was pushed to pelvic region.
There are many treatment options available for protrusion of shunt through anus, which includes exploratory laparotomy with primary closure of bowel and removal of shunt in case of peritonitis, mini laparotomy with revision of peritoneal part of shunt if no peritonitis is present, shunt removal with external drainage of CSF, antibiotics followed by VP shunt or VA shunt, flexible pediatric colonoscope used to locate, and removal of peritoneal part of shunt without bowel closure in absence of peritonitis.
It can be concluded that, this rare complication of VP shunt must be kept in mind especially with patients having nonfunctioning of shunt without evidence of meningitis or peritonitis. Silent bowel perforation in patients with VP shunt should be investigated ideally with contrast-enhanced CT abdomen. Later on, these patients may present with peritoneal end of catheter coming out of anus. Revision of shunt should be considered only if patient become symptomatic again as patient may have developed compensatory mechanism for hydrocephalous and should be followed-up for a long time to determine the need for revision of shunt later on.
| References|| |
|1.||Ghritlaharey RK, Budhwani KS, Shrivastava DK, Gupta G, Kushwaha AS, Chanchlani R, et al. Trans-anal protrusion of ventriculoperitoneal shunt catheter with silent bowel perforation: Report of ten cases in children. Pediatr Surg Int 2007;23:575-80. |
|2.||Acharya R, Ramachandran CS, Singh S. Laproscopic management of abdominal complications in ventriculoperitoneal shunt surgery. J Laparoendosc Adv Surg Tech A 2001;11:167-70. |
|3.||Gupta R. Migrated ventriculoperitoneal shunt in inguinal hernial sac. Indian J Surg 2003;65:186-7. |
|4.||Yilmaz N, Krymaz N, Yilmaz C, Casken H, Yuca SA. Anal protrusion of ventriculoperitoneal shunt catheter: Reports of two infants. J Pediatr Neurol 2004;2:241-4. |
|5.||Wilson CB, Bertan V. Perforation of bowel complicating peritoneal shunt for hydrocephalus. Report of two cases. Am Surg 1996;32:601-3. |
|6.||Wani AA, Ramzan A, Wani MA. Protrusion of a peritoneal catheter through the umbilicus: An unusual complication of a ventriculoperitoneal shunt. Pediatr Surg Int 2002;18:171-2. |
|7.||Grover S, Menon P, Samujh R, Rao KL. Congenital hydrocephalus: A comparative study on the efficacy and complications after low versus medium pressure ventriculoperitoneal shunt. J Indian Assoc Pediatr Surg 2004;9:143-7. |
|8.||Couldwell WT, LeMay DR, McComb JG. Experience with use of extended length peritoneal shunt catheters. J Neurosurg 1996;85:425-7. |
[Figure 1], [Figure 2], [Figure 3]