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Silent bowel perforation cause by migration of ventriculoperitoneal shunt masquerading as acute enteritis.

Byline: Hsiao-Kuei. Chang, Shih-Hung. Tsai, Yu-Long. Chen, Yuan-Pin. Hsu

Ventriculoperitoneal (VP) shunt is an established method of diverting cerebrospinal fluid for the management of hydrocephalus. The procedure is associated with various complications. Bowel perforation caused by migration of VP shunt is rare but serious complication. Because most of the patients are asymptomatic, and the occurrence of such complication is fatal due to ascending meningitis, early diagnosis, and rapid treatment is important in these patients. The diagnosis of such complication is based on direct visual of the protruding tube from the anus or abdominal computed tomography. Colon perforation due to shunt catheter migration may initially but not essentially present as meningitis after shunt infection, abdominal symptoms, seizure, and fever. However, colon perforation may rarely resemble the symptoms of acute gastroenteritis (abdominal pain, vomiting and/or diarrhea) before the prolapse of shunt catheter from the rectum. Here, we report a 75-year-old man underwent VP shunt for hydrocephalus presented with "watery diarrhea" masqueraded as acute gastroenteritis and further diagnosed as migration of VP shunt from the colon, via digital examination and further disclosed by computed tomography.

Introduction

Ventriculoperitoneal (VP) shunt surgery is the standard treatment for hydrocephalus since 100 years ago, which allows the drainage of cerebrospinal fluid (CSF) via a catheter into the peritoneal cavity. In addition to the most common shunt complications - obstruction and infection - VP shunts have been associated with a variety of abdominal complications, which affect 10-30% of patients. [sup][1] Bowel perforation after VP shunting is extremely uncommon and accounts <0.1% of all abdominal complications. Over 50% of these patients are asymptomatic, however, the mortality rate associated with it is as high as 15%. [sup][1]

Case Report

A 75-year-old man had undergone revision of VP shunt for normal hydrocephalus 2 months ago. He presented to the emergency department (ED) with frequent passage of "watery" diarrhea, of 1-week duration. Initially, he went to the local clinic and took some antidiarrheal agent under impression of acute enteritis, but the symptom persisted. When he arrived in our ED, his body temperature was 36.1[degrees]C, his blood pressure was 115/68 mm Hg, his pulse rate was 88 beats/min, and his respiratory rate was 20 breaths/min. The abdominal examinations were normal. Our laboratory examination showed a white cell count of 5400/[micro]L, with neutrophils at 56.2%, lymphocytes at 32.3%, hemoglobin at 12.4 g/dl, hematocrit at 36.5%, platelets at 162 x 10 [sup]3 /[micro]l, C-reactive protein at 0.1 mg/dl, aspartate aminotransferase at 18 U/L, alanine aminotransferase at 13 U/L, blood urea nitrogen at 22 mg/dl, creatinine at 1.4 mg/dl. Stool examination revealed normal. The "stool" looked clear and low volume. The stool made the underwear wet. The patient stated he had wet underwear needed to the frequency change in a day during the previous 1-week. The general appearance of anal orifice is normal. The digital examination revealed a foreign body sensation of the finger. The foreign body was pulled out. It disclosed a yellowish plastic tube [Figure 1]. Abdominal computed tomography revealed VP shunt migrated from the colon distal to the anus [Figure 2], which was consistent with the digital examination finding. The patient was treated with revision of VP shunt and broad spectrum antibiotics. As a result, he discharged under stable condition 2-week later.{Figure 1}{Figure 2}

Discussion

Hydrocephalus is a pathological state of CSF accumulation, which leads to the dilatation of the cerebral ventricles. The management of hydrocephalus includes the drainage of CSF through a subcutaneous catheter into an absorption site that is most frequently the peritoneum.

Several complications including disconnection and/or occlusion of the tube, shunt infection, intestinal obstruction, migration of the shunt, and perforation of the internal organs have been reported in association with the VP shunt.

Among the internal organ perforations, bowel is the most common site of perforation by a VP shunt catheter and is a rare but serious complication occurring in <1% of cases with mortality of up to 15%. [sup][1] The exact pathophysiology of bowel perforation is still a matter of debate; adherence of the tip of the VP catheter to the bowel wall and subsequent local inflammation and erosion, [sup][2] encasing fibrosis around the tube, [sup][3],[4] and silicone allergy leading to a foreign body-like reaction [sup][5] have been regarded as the possible mechanisms of bowel perforation. Furthermore, younger age [sup][6],[7] and myelomeningocele [sup][8] may be contributing factors to developing perforation; the latter gives rise to weakness in the bowel wall due to the defective innervations. In the present case, adhesions along with fibrosis were seen between the peritoneal tube and the colon near the perforating site.

Although the incidence of bowel perforation due to VP catheter is low, the mortality rate is high. Therefore, early diagnosis is important, but it may be difficult because nearly half of these cases are asymptomatic. The most frequent finding is VP catheter dislodgement through the anus, [sup][1] therefore, this extrusion seems like a chance for early diagnosis of bowel perforation. In contrast, colon perforation may rarely resemble the symptoms of acute gastroenteritis (abdominal pain, vomiting, and/or diarrhea) before the prolapse of shunt catheter from the rectum. Associated diarrhea may occur because of the CSF drainage via the catheter into the colon. Thereby, nausea and vomiting may be among the neurological symptoms of hyponatremia because of excessive CSF loss. In our present case, the patient presented with the symptoms of acute gastroenteritis without any apparent peritoneal signs, the "watery" diarrhea (clear and low volume "stool") may be the only hint, than digital examination was performed. Diagnosis was made according to shunt catheter protruding from the anus during digital examination.

Ruling out of central nervous system (CNS), and intra-abdominal infection by retrograde spread is the initial step in the management of bowel perforation. The removal of the shunt catheter along with short-term external ventriculostomy and intravenous antibiotics has been used as a treatment of VP shunt-related colonic perforation. The protruding catheter can be removed by pulling it through the anus, surgical removal, or endoscopic removal, based on the clinical state of the patient. Surgical intervention is indicated for cases in which clinical findings of peritonitis or CNS infection are significant. In contrast, if there is no retrograde infection, endoscopic removal of the catheter may be considered in case of a more proximal location of the distal tip or a resistance while pulling the catheter. In nonsurgical options of removal, the perforation site is believed to be plugged due to the presence of a fibrous sheath around the shunt tract. [sup][9],[10],[11] In the present case, the penetration site of the VP catheter was established by preoperative colonoscopy to localize the minimal laparotomy incision.

Conclusion

Ventriculoperitoneal shunt-related colonic perforation is a rare but fatal complication. Our present case exhibited that clinical suspicion of bowel perforation should be focused on any patient with a VP shunt presenting with prolonged diarrhea of unknown etiology, abdominal symptoms, and gastroenteritis.

References

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2. Shetty PG, Fatterpekar GM, Sahani DV, Shroff MM. Pneumocephalus secondary to colonic perforation by ventriculoperitoneal shunt catheter. Br J Radiol 1999;72:704-5.

3. Ali J, Cheah FK. Per rectal extrusion of a ventriculo peritoneal shunt catheter. A case report. Med J Malaysia 1987;42:201-3.

4. Rubin RC, Ghatak NR, Visudhipan P. Asymptomatic perforated viscus and gram-negative ventriculitis as a complication of valve-regulated ventriculoperitoneal shunts. Report of two cases. J Neurosurg 1972;37:616-8.

5. Brownlee JD, Brodkey JS, Schaefer IK. Colonic perforation by ventriculoperitoneal shunt tubing: A case of suspected silicone allergy. Surg Neurol 1998;49:21-4.

6. Adeloye A, Olumide AA. Abdominal complications of ventriculoperitoneal shunts in Nigerians. Int Surg 1977;62:525-7.

7. Nishijima M, Endoh S, Ohyama H, Higuchi H. Gastric perforation by a ventriculoperitoneal shunt. Neurosurgery 1982;10:754-6.

8. Adeloye A. Protrusion of ventriculo peritoneal shunt through the anus: Report of two cases. East Afr Med J 1997;74:337-9.

9. Schulhof LA, Worth RM, Kalsbeck JE. Bowel perforation due to peritoneal shunt. A report of seven cases and a review of the literature. Surg Neurol 1975;3:265-9.

10. Snow RB, Lavyne MH, Fraser RA. Colonic perforation by ventriculoperitoneal shunts. Surg Neurol 1986;25:173-7.

11. Sharma BS, Kak VK. Multiple subdural abscesses following colonic perforation - A rare complication of a ventriculoperitoneal shunt. Pediatr Radiol 1988;18:407-8.
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Article Details
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Title Annotation:Case Report
Author:Chang, Hsiao-Kuei; Tsai, Shih-Hung; Chen, Yu-Long; Hsu, Yuan-Pin
Publication:Journal of Medical Sciences
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2014
Words:1445
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