VP SHUNT IN THE COLON: A RARE AND MISSED COMPLICATION
Anas Khouri*, Elizabeth Craig, Benjamin Niland
Internal Medicine, University of South Alabama, Mobile, AL
Introduction:
A ventriculoperitoneal shunt (VP) is the most common surgical treatment for patients with hydrocephalus. The peritoneal cavity, with its large surface, serves as an optimal location and is often used for CSF drainage. However, due to its thin layers and the consistency of the shunt tube, many complications can arise. Migration of the shunt and perforation of the colon is an uncommon complication and is associated with high morbidity and mortality. We present a case involving a 66-year-old patient with a VP shunt that eroded into the transverse colon along with our treatment approach.
Case report:
66-year-old patient with a history of subdural hematoma and craniectomy, with subsequent hydrocephalus and VP shunt placement, presented 6 months after shunt placement due to a low hemoglobin (5.2 mg/dl) at his nursing home. He had no overt bleeding or altered mental status. He denied other symptoms including abdominal pain, nausea, vomiting, or fever. He was resuscitated and a workup for bleeding/infection was initiated. Due to a history of arteriovenous malformations in the duodenum, GI was consulted for evaluation of anemia. EGD and colonoscopy (CSC) were performed. CSC showed the VP shunt eroding into the colon (Figure 1). CT scan showed the shunt in the transverse colon (Figure 2). Of note, the CT scan initially did not detect the perforation prior to direct visualization during CSC. A multidisciplinary discussion between GI, Neurosurgery, and General Surgery resulted in a decision to perform a laparotomy with distal VP shunt removal. The shunt was cut at the entrance of the colon, and the contaminated part was removed. The enterotomy was surgically repaired, leaving about 5 cm of intraabdominal distal shunt in place. Antibiotic powder was placed around the VP shunt. The patient tolerated the procedure well and improved following surgery.
Discussion:
Ventriculoperitoneal shunts can be associated with a magnitude of complications. Abdominal complications can occur in 10-30% of cases and can include abdominal pain, peritonitis, formation of pseudocysts. Migration of the shunt to the intestines with erosion into the colon is a rare complication (0.1 to 0.7% of abdominal complications), and more common in the pediatric population. This is associated with high morbidity and mortality (15%), and prompt recognition and treatment are crucial. A perforation can be easily missed on CT scan, particularly if the patient's presentation is not consistent with shunt dysfunction. There are multiple treatment options described in the literature that focus on removal of the shunt from the bowel. Laparotomy, percutaneous, endoscopic, and peranal approaches have been described. However, no standard of care is established, and the treatment approach is usually individualized. CSF cultures should be monitored following the surgery due to a high risk of infection.
Colonoscopy showing the VP shunt eroding into the colon
CT scan showing the shunt in transverse colon at the splenic flexure
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