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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 4  |  Issue : 6  |  Page : 290-291

Peroral extrusion of the peritoneal catheter in an infant


1 Department of Surgery, M.M. Institute of Medical Sciences and Research, Mullana, Ambala, Haryana, India
2 Department of Surgery, Government Medical College, Jammu, India
3 Department of Radiodiagnosis, Government Medical College, Jammu, India

Date of Web Publication14-Jun-2012

Correspondence Address:
Mahesh Gupta
Department of Surgery, M.M. Institute of Medical Sciences and Research, Mullana, Dist. Ambala, Haryana - 133 203
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1947-2714.97214

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  Abstract 

Peroral extrusion of the distal end of a ventriculo-peritoneal shunt tube is the potentially hazardous end result of a bowel perforation with only few case reports in the literature. The distal end of the peritoneal catheter got fractured in a 4-year-old child and it protruded out through the mouth. The cranial incision was opened and the shunt divided below the chamber. The ventricular end and the chamber and distal end were removed through this incision. In the present successfully managed case we review the current strategies in the management of such a rare complication and discuss the possible pathogenesis of this entity.

Keywords: Bowel perforation, Hydrocephalus, Oral extrusion, Ventriculo-perioneal shunt


How to cite this article:
Gupta M, Digra NC, Sharma N, Goyal S, Agrawal A. Peroral extrusion of the peritoneal catheter in an infant. North Am J Med Sci 2012;4:290-1

How to cite this URL:
Gupta M, Digra NC, Sharma N, Goyal S, Agrawal A. Peroral extrusion of the peritoneal catheter in an infant. North Am J Med Sci [serial online] 2012 [cited 2019 Nov 20];4:290-1. Available from: http://www.najms.org/text.asp?2012/4/6/290/97214


  Introduction Top


Ventriculoperitoneal (VP) shunt surgery is one of the most commonly used techniques for the treatment of hydrocephalus and can be associated with a number of complications and if not recognized in a timely manner these complications can be fatal. [1],[2],[3] One such rare complication is peroral extrusion of the distal end of a ventriculo-peritoneal that can be the end result of a bowel perforation by shunt catheter. [1],[3],[4],[5],[6],[7],[8],[9],[10]

In present successfully managed case, we review the current strategies in the management of such a rare complication and discuss the possible pathogenesis of this rare complication.


  Case Report Top


A 4-year male child presented with the history of one episode of vomiting and following which the parents noticed that there was a tube protruding through the mouth. The distal end of the peritoneal catheter got fractured and parents brought the same with them. The child was operated for congenital hydrocephalus at the age of 6 months and a right ventriculo-peritoneal shunt was placed. He was asymptomatic since that time with normal development. There was no history of features of meningitis or intestinal obstruction including pain abdomen. There was no history of fever, excessive crying, or any significant problem preceding this event.

On admission to the hospital, the patient was conscious, had spontaneous eye opening, and had no neurological deficits. The shunt tract was normal with no signs of inflammation. The abdomen was soft and bowel sounds were normal. Plain radiography showed no displacement of the cranial end of the shunt tube; however the peritoneal end was seen traversing posteriorly to the stomach on the left side and entering into the stomach in a retrograde manner [Figure 1] and [Figure 2].
Figure 1: Plain X-ray film showing the peritoneal end of the shunt along with the nasogastric tube in the stomach (in inset please note the bile staining of the peritoneal catheter)

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Figure 2 (a-f): CT scan showing the trajectory of the peritoneal end as seen that it is traversing posterior to the stomach on the left side and entering into the stomach in a retrograde manner, perforating probably the stomach

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It was decided to remove the shunt and decide regarding the need for replacement depending upon the presence or absence of infection. The cranial incision was opened and the shunt divided below the chamber. The ventricular end and the chamber and distal end were removed through this incision. The child was maintained on intravenous fluids and antibiotics for 36 hours. The child was then started on oral feeds, which he tolerated well. He was given cephalosporin antibiotics.

The child was discharged after 2 weeks, at which time he was totally asymptomatic. At 12-month follow-up the child remained asymptomatic.


  Discussion Top


Spontaneous bowel perforation is a rare complication of a VP Shunt, seen in only 0.01-0.07% of cases, [5],[11] Extrusion most commonly occurs through the anal orifice (61.9%) [9] and peroral extrusion is extremely rare. [1],[3],[4],[5],[6],[7],[8],[9],[10] Usually these patients present with features of ventriculitis or meningitis due to an enteric organism, as in the present case patients with proximal perforations involving stomach or proximal jejunum are less prone to severe infectious complications than are perforations of the distal intestine like the colon. [4] It has not been clear why the shunt tube should extrude through the mouth although it has been proposed that shunt tract infection can probably lead to inflammation and adherence of the tube to the proximal gut and subsequent perforation. [4]

In the present case probably the peritoneal end was traversed behind the stomach and trapped at some point and was continued to be pushed behind by the intraabdominal pressure creating a vicious cycle resulting in the perforation of stomach as was supported by the trajectory of the tubing on imaging findings. As in the present case once perforated and lying in the stomach or the jejunum, the tube may be made to travel into the oral cavity by forceful repeated vomiting and retching, [4] bowel perforation and shunt tube extrusion do not always have a benign course and can be associated with very high mortality. [1],[3],[4],[10]

Due to rarity of such complication, the correct management is not certain; however peroral extrusion of the shunt tube needs prompt treatment. The first step should be to look for any infection and for shunt tract inflammation, followed by removal of extruded shunt tube and the ventricular end through a clean cranial incision, and attention to bowel perforation. [4] Most of the time in these patients a major laparotomy is not necessary as the opening in the bowel is small and can seal off spontaneously. [4],[10]

Although majority of the patients will need replacement of the shunt device; however, as in the present case, a few may not require the replacement of shunt due to spontaneous opening up of CSF pathways which were not yet mature when the initial shunt was placed, making the patient shunt independent. [4]

 
  References Top

1.Berhouma M, Messerer M, Houissa S, Khaldi M. Transoral protrusion of a peritoneal catheter: A rare complication of ventriculoperitoneal shunt. Pediatr Neurosurg 2008;44:169-71.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Di Rocco C, Marchese E, Velardi F. A survey of the first complication of newly implanted CSF shunt devices for the treatment of nontumoral hydrocephalus. Cooperative survey of the 1991-1992 Education Committee of the ISPN. Childs Nerv Syst 1994;10:321-7.  Back to cited text no. 2
[PUBMED]    
3.Griffith JA, DeFeo D. Peroral extrusion of a ventriculoperitoneal shunt catheter. Neurosurgery 1987;21:259-61.  Back to cited text no. 3
[PUBMED]    
4.Sridhar K, Karmarkar V. Peroral extrusion of ventriculoperitoneal shunt: Case report and review of literature. Neurol India 2009;57:334-6.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Vinchon M, Baroncini M, Laurent T, Patrick D. Bowel perforation caused by peritoneal shunt catheters: Diagnosis and treatment. Neurosurgery 2006;58 Suppl 1:ONS76-82.  Back to cited text no. 5
    
6.Dua R, Jain R. Peroral extrusion of ventriculoperitoneal shunt: A case report and review of the literature. Cen Eur Neurosurg 2011;72:107-8.  Back to cited text no. 6
    
7.Fermin S, Fernandez-Guerra RA, Sureda PJ. Extrusion of peritoneal catheter through the mouth. Childs Nerv Syst 1996;12:553-5.  Back to cited text no. 7
    
8.Jimenez Moya A, Penela Velez De Guevara T, Gracia Remiro R, Romero Escos D, Santana Rodriguez C, Reig Del Moral C, et al. Extrusion of a ventriculoperitoneal shunt catheter through the mouth. An Esp Pediatr 2001;54:609-10.  Back to cited text no. 8
    
9.Odebode TO. Jejunal perforation and peroral extrusion of a peritoneal shunt catheter. Br J Neurosurg 2007;21:235-6.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Park CK, Wang KC, Seo JK, Cho BK. Transoral protrusion of a peritoneal catheter: A case report and literature review. Childs Nerv Syst 2000;16:184-9.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Sathyanarayana S, Wylen EL, Baskaya MK, Nanda A. Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: Case report and a review of 45 cases. Surg Neurol 2000;54:388-96.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2]


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