A 17 year old girl with a myelomeningocele has a long-standing VP shunt, which was last revised two years ago. Recently, the patient noticed VP shunt tubing extruding from her anus. On physical examination, she has no abdominal tenderness and the shunt tubing was not seen. Imaging including shunt series and CT scan of the abdomen shows that the shunt is intracolonic with the tip located in the distal sigmoid colon. In addition to IV antibiotics and externalizing the shunt, the best next step in the management of this patient is?

 

 

 

[size=20px]A Sigmoidoscopy

 

B Paracentesis

 

C Diagnostic laparoscopy

 

D Exploratory laparotomy

 

E Remove entire shunt system[/size]

E

E

E

D

A- sigmoidoscopy

A

A

A

Correct answer

A Sigmoidoscopy

 

Intestinal perforation from a ventriculoperitoneal shunt is a rare complication. There are case reports of children presenting with a transanal protrusion of the catheter as the initial presenting symptom. Initial assessment of the child should include evaluation of peritoneal signs and symptomatology. Cross sectional imaging and shuntogram can help guide the diagnosis. Initiation of antibiotics is recommended with early shunt externalization. Often the cranial portion of the catheter is salvageable without the need for replacement of the entire system in the absence of positive cerebrospinal fluid cultures. The distal portion of the catheter can often be removed using endoscopic techniques without the need for initial laparoscopy or laparotomy. Once the child has recovered with no ongoing concern for meningitis a combined approach with laparoscopic assistance can be helpful for replacement of the distal portion of the catheter.