TRANS-ANAL PROTRUSION OF VENTRICULOPERITONEAL SHUNT WITH ASSOCIATED BOWEL PERFORATION AND FISTULA FORMATION: A CASE REPORT

Objectives: Background
Ventriculoperitoneal (VP) shunt is the most common surgical procedure to treat hydrocephalus. VP shunts have been known to perforate organs causing complications. The patients with bowel perforation presented in many ways, some without any abdominal symptoms. Many presented with catheter malfunction, meningitis, anal extrusion of catheter, fever, or cutaneous symptoms. Our patient presented with no abdominal symptoms and was diagnosed with encephalitis and meningitis initially before discovering protrusion of his shunt catheter from his anus days into his hospital stay.

Case Description
This case report describes an adult patient who underwent VP shunt placement 5 years prior.
The patient presented with VP shunt protrusion from his anus. He underwent surgical exploration and the VP shunt catheter was seen crossing from his right upper quadrant and diving into his left lower quadrant disappearing into the sigmoid colon. A 7-centimeter fistula tract was noted between the colon and the shunt. In addition, the appendix was wrapped around the VP shunt catheter and firmly adhered to it.

Conclusion
Shunt migration and perforation yields a direct tract from the abdomen and bowels to the brain allowing for easy migration of bacteria into the neurological system. Patients can present relatively asymptomatic or with sepsis due to delay in diagnosis of the shunt perforation. This case report examines this patient’s unique case and presentation as the perforation was likely chronic as evidenced by the fistula formation and bowel adherence to the VP shunt. Protrusion of the shunt through the anus has only been seen in a small number of patients. Once diagnosed, VP shunt perforation is a surgical emergency requiring removal of the shunt and treatment with antibiotics. Our patient was able to be treated with shunt removal, surgical treatment of the perforation and resection of the fistula tract, and continued antibiotics.

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