SAEM Clinical Images Series: An Unusual Foreign Body

vp shunt

A 61-year-old female with a past medical history of hypertension, hyperlipidemia, type 2 diabetes, and normal pressure hydrocephalus s/p VP shunt (last revision nine months ago) presented to the Emergency Department (ED) for evaluation after noticing a “string” coming out of her anus today. Associated symptoms included nausea and a mild headache for one day, and one episode of vomiting prior to arrival. The patient denied abdominal pain, dizziness, fever, chills, diarrhea, and constipation. She had no other complaints on a complete review of systems. Past surgical history was significant for laparoscopic ventral hernia repair with mesh and lysis of adhesions (three years ago), as well as prior appendectomy, cholecystectomy, c-section, and right nephrectomy.

Additional Images

Physical Exam

Vitals: Temp 98.4°F (36.9°C); BP 110/56; HR 64; RR 16; SpO2 100%

General: No acute distress, well appearing.

Neck: Supple, non-tender, no meningismus, full and painless range of motion.

Abdomen: Soft, nontender, nondistended. No peritoneal signs.

Neuro: Awake, alert and oriented x3, no focal neurologic deficits.

Rectum: Narrow lumen tube-like structure protruding from anus. Soft stool present at anus with no blood or melena. Non-tender rectal exam.

Laboratory Data

Complete Blood Count (CBC): No leukocytosis, no anemia

Comprehensive Metabolic Panel (CMP): Within normal limits

Case Question: What is the diagnosis and how do we confirm it?

Ventriculoperitoneal shunt erosion into the intestinal tract

Diagnosis can be established with abdominal imaging including VP Shuntogram X-ray series. A CT abdomen/pelvis would also be confirmatory imaging while assisting in ruling out other intra-abdominal complications such as bowel perforation, abscesses or other diseases.

Case Question: What is the ED management of this patient once the diagnosis has been confirmed?

Broad-spectrum empiric antibiotics with CNS coverage should be started for treatment of presumed intra-abdominal, bloodstream, and/or CNS infection. General surgery and neurosurgery should be consulted emergently for evaluation. Bloodwork and a full infectious workup including blood cultures should be done. CSF cultures should be considered as well, in consultation with a neurosurgeon. Patients are at high risk of bacterial spread to the abdomen or retrograde spread up the ventriculoperitoneal shunt leading to peritonitis, peritoneal abscess, ventriculitis, meningitis, or sepsis. Further indicated invasive/surgical interventions should be deferred to general surgery and neurosurgery consultants. Our patient had a confirmatory CT abdomen/pelvis showing the VP shunt catheter perforation into the sigmoid colon and exiting through the rectum. The patient was started on vancomycin, cefepime, and flagyl. General surgery and neurosurgery were consulted and the patient was taken the same day to the OR for laparoscopy and externalization of VP shunt from bowel.

Case Discussion

Take-Home Points

Bowel perforation is a rare but serious complication of ventriculoperitoneal shunts.
Diagnosis should be considered even in patients who present with no meningeal or peritonitic signs.
Imaging should be obtained to confirm diagnosis, and broad-spectrum antibiotics with CNS coverage should be started early.
General surgery and neurosurgery should be consulted emergently for further operative interventions.

References

Paff, M, Alexandru-Abrams, D, Muhonen, M, Loudon, W. (2018). Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery, 13, 66-70.
Bales J, Morton RP, Airhart N, Flum D, Avellino AM. Transanal presentation of a distal ventriculoperitoneal shunt catheter: Management of bowel perforation without laparotomy. Surg Neurol Int. 2016 Dec 28;7(Suppl 44):S1150-S1153. doi: 10.4103/2152-7806.196930. PMID: 28194303; PMCID: PMC5299151.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.