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RECURRENT SMALL BOWEL OBSTRUCTION SECONDARY TO ABDOMINAL PSEUDOCYST ASSOCIATED WITH LONG-TERM VENTRICULOPERITONEAL SHUNT: A CASE REPORT
Arezou Abbasi
*, Yasaman Vaseghi, Abbas Mohammadi, Alex Akhondi Asl, Brian Carlson
Internal Medicine, Universal Health Services Inc, King of Prussia, PA
Objective:Abdominal Pseudocyst (APC) is a rare but challenging complication of ventriculoperitoneal shunt (VPS). The incidence is unknown with limited number of case reports. VPS-associated APC is defined as cerebrospinal fluid (CSF) collection in the peritoneum that is walled off with a non-epithelialized fibrinous capsule. If large, it may manifest with pressure effect on adjacent organs (e.g. intestines, IVC). Hypothetical risk factors include chronic inflammatory process, shunt infection or reduced capacity of peritoneal cavity to absorb fluid. Majority of the reported cases are pediatric patients. Here, we present an adult patient with VPS-associated APC with recurrent episodes of small bowel obstruction (SBO).
Case Presentation:The patient is a 35-year-old male with Chiari II malformation and spina bifida who presented with nausea, vomiting, bilateral flank pain, abdominal distention, and no bowel movement for five days. Upon arrival, he was hemodynamically stable and remained stable throughout his hospitalization. As a newborn, he had undergone VPS placement during myelomeningocele repair and a one-time shunt revision when he was 5 years old.
Workup showed urinary tract infection with multidrug-resistant Enterobacter Cloacae, along with a moderate-size APC surrounding the distal tip of the VPS, distention of the stomach and proximal small bowel compatible with SBO. Despite bowel rest, and nasogastric tube decompression, he did not have bowel movement by hospital day three. A repeat CT scan showed significant increase in the size of the APC with distended small bowel loops containing air-fluid level surrounded by the APC. Head CT did not show any obvious shunt malfunction. At this point, the patient refused any IR or surgical intervention. Therefore, medical management was continued. On hospital day eight, he had bowel movement, was able to tolerate a liquid diet and was discharged. One week later, he was admitted to another center with similar symptoms. Following CT-guided aspiration of three-liter clear abdominal fluid, his symptoms significantly improved. Fluid culture was negative. Given recurrent episodes of SBO, ultimately the patient agreed to undergo APC resection with repositioning of the VPS into the right lower quadrant. CT scan in 1 week showed re-accumulation of CSF, demonstrating unsatisfactory resorption of fluid from peritoneum. Therefore, the patient underwent complete removal of VPS system and creation of ventriculo-atrial shunt. The patient’s recovery was uneventful in three months follow up.
Discussion:APC should be considered in any adult patient with VPS who presents with abdominal symptoms. Management is determined by each patient’s overall clinical status and presentation.
However, complete removal of VPS system and creation of ventriculo-atrial shunt can be considered as definitive management in an adult patient.
Figure 1. Abdominal pseudocyst containing contrast enhanced loops of small bowel and VP shunt
Figure 2. Coronal view of the abdominal pseudocyst
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