|LETTER TO THE EDITOR
|Year : 2017 | Volume
| Issue : 2 | Page : 216-217
Shunt tip perforating large bowel through vermiform appendix
Sushanta Kumar Sahoo, Chhitij Srivastava, Ashish Tomar
Department of Neurosurgery, KGMU, Lucknow, Uttar Pradesh, India
|Date of Web Publication||14-Mar-2017|
Sushanta Kumar Sahoo
Department of Neurosurgery, KGMU, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sahoo SK, Srivastava C, Tomar A. Shunt tip perforating large bowel through vermiform appendix. Med J DY Patil Univ 2017;10:216-7
Complications associated with ventriculoperitoneal shunts (VPSs) are not uncommon. Extrusion of the peritoneal end of the VPS through natural orifices as well as intact abdominal wall has been reported., We present a case of VPS tip eroding through the vermiform appendix to enter the large bowel.
A 2-year-old male child who was operated previously for congenital hydrocephalus (right-sided VPS) presented with complaints of vomiting and poor feed. His mother gave a history of shunt prolapsed through the anal canal 1 day before hospitalization, which got retracted back without intervention. Clinically, no signs of peritonitis were present. X-ray abdomen showed shunt along the course of large bowel up to the sigmoid colon [Figure 1]b. Computerized tomography scan showed no features of hydrocephalus [Figure 1]a. Therefore, shunt removal was planned with an initial exploration of the abdominal end. The shunt was found entering into the tip of the appendix, when pulled it was fecal stained [Figure 1]c,[Figure 1]d,[Figure 1]e. The whole shunt system was removed after disconnecting it from the cranial end, and appendicectomy was done. The child was kept under observation as there was no feature suggestive of hydrocephalus.
|Figure 1: (a) Computed tomography scan showing ventricular end of the shunt. Note there are no features of hydrocephalus. (b) Shunt along the large bowel loop up to the level of sigmoid colon. (c-e) Shunt tip entry through the appendix tip and the fecal stained pulled out shunt|
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VPS tip perforating the bowel and extruding through mouth, urethra, anal canal, intact abdominal wall as well as invading the cardiovascular system have been reported in literature.,, Some of the patient-related factors responsible for this include poor nutritional status, low immunity, obesity, and local wound infection. The stiff and sharp-cut end of the VPS tip with pulsatile cerebrospinal fluid (CSF) flow has also been proposed as causative factors for bowel wall perforation. Moreover, the poorly developed intestinal musculature is considered to be responsible for higher incidence of such complications in pediatric age group. Recently, one study showed the incidences of intestinal perforations are more common with Chhabra shunt than another shunt type. However, they concluded that the perforation could not be related to shunt catheter stiffness.
Often the intestinal perforation activity remains inconspicuous. Perhaps the shunt tip gradually erodes the bowel wallowing to the pulsatile CSF flow along with simultaneous fibrosis surrounding it, preventing any spillage of bowel content. However, shunt tip eroding through the mobile appendix tip is very unusual. It can be speculated that this child had subacute appendicitis and the shunt tip present in the right iliac fossa might have got adhered to it leading to progressive erosion of the bowel wall. The usual treatment suggested is shunt removal by pulling it out from the extruded side after disconnecting it from the cranial end. The shunt has to be cut just distal to the chamber before pulling it out from the extruded end. Patients may require further CSF diversion procedures if develop features of hydrocephalus.
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Conflicts of interest
There are no conflicts of interest.
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