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  • br Case report A year old boy with a

    2018-10-22


    Case report A 3-year-old boy with a history of traumatic subarachnoid hemorrhage and skull fracture at age 1.5 months developed hydrocephalus and underwent VPS at 9 months. At 18-months old, the VP shunt was replaced with a new shunt because of infection. Eighteen months later, he experienced abdominal pain for 3 days, and his mother discovered a tube protruding from his Lomustine following defecation (Figure 1). The abdominal pain was intermittent and typically resolved spontaneously after several hours. He did not experience fever, chillness, nausea, vomiting, or melena. On admission, he had clear consciousness, stable vital signs, a body temperature of 36.8°C, and no neck stiffness. He had mild epigastric tenderness, but did not display any peritoneal signs. A 10-cm yellowish tube was protruding from the anus, with clear fluid draining from it. A complete blood count showed hemoglobin of 12.0 g/dL and a white blood-cell count of 7.12 × 103/μL, with 41.2% neutrophils and 49.6% lymphocytes. Serum biochemistry and cerebrospinal fluid (CSF) examinations were normal, and the CSF culture yielded no growth. A plain abdominal roentgenogram revealed focal ileus at the mid-abdomen and the peritoneal tube of the VP shunt encircling the abdomen and progressing to the perineal region (Figure 2A). Abdominal computed tomography (CT) revealed that the tube penetrated one segment of the small intestine and progressed distally in the colon (Figures 2B and 2D). Free air or ascites were not observed. We performed laparoscopic exploration by administering broad-spectrum antibiotics, because of the focal ileus and because the patient continued to experience intermittent abdominal pain. Initially, the proximal part of the peritoneal tube of the VP shunt was cut at the right side of the neck. Subsequently, laparoscopy was performed, during which tight adhesion was observed in the abdomen. A thick fibrous bundle encasing the peritoneal tube extended from the right upper abdominal wall to the terminal ileum, with adhesion between the peritoneal tube and the ileum. The fibrous bundle entered the terminal ileum following lysis of the adhesion ∼25 cm proximal to the ileocecal valve. The fibrous bundle and the terminal ileum were subsequently withdrawn from the laparoscopic port wound at the umbilicus. After removal of the fibrous tissues, the peritoneal tube was excised at its ileum entry, the distal end was withdrawn from the anus, and the proximal end was removed from the ileum extracorporeally. The fibrous tissue and perforation site were excised, and the ileum was repaired extracorporeally. Antibiotic treatment was continued after surgery, and the patient recovered well. He was discharged 6 days after surgery, and the oral antibiotic treatment was continued for 2 weeks. Later, his shunt was further managed by a neurosurgeon half a year later.
    Discussion Among VPS-induced gastrointestinal perforations, colonic perforation constitutes the majority, whereas perforations of the stomach and small intestine are rare, with small-intestinal perforation being the rarest. Additionally, all patients manifesting peritoneal-tube transanal protrusion have been diagnosed with colonic perforation. Our case is the only report of small-intestinal perforation and peritoneal-tube transanal protrusion. Such bowel perforations are associated with fibrosis encasing the tube, which anchors the tube and exerts pressure on the bowel area, due to foreign-body reaction. This pressure coupled with the continuous hammer effect of CSF pulsations may eventually cause the bowel to erode, resulting in the perforation. Moreover, a thick fibrous bundle encasing the peritoneal tube and extending from the right upper abdominal wall to the terminal ileum was observed in our patient. Only seven cases of VPS-induced small-intestinal perforation have been reported (Table 1). The perforation sites were the jejunum in three patients (proximal jejunum, middle jejunum, and an unknown location in the jejunum), ileum in two patients (25 cm and 75 cm proximal to the ileocecal valve), and unknown locations in the small intestine in two patients. The mean interval between shunting and the onset of symptoms was 16.3 months (range, 2.5 months–3 years). Furthermore, the clinical manifestations were as follows: shunt dysfunction and CNS infection in two patients, and peritonitis, intestinal obstruction, and skin erosion with shunt-tube infection and transoral protrusion in one patient each. The remaining two patients died of congestive heart failure and recurrent medulloblastoma with CNS infection; their intestinal perforations were diagnosed at autopsy. The intestinal perforations in the surviving patients were diagnosed by injecting contrast medium into the shunt tube (shuntogram) in one patient, surgery in two patients, and shuntogram and surgery in two patients. The five surviving patients underwent surgery, which predominantly consisted of peritoneal-tube removal and proximal diversion, followed by VP-shunt revision. Additionally, two patients underwent laparotomy, with one patient each underwent intestinal resection and volvulus derotation with intestinal perforation closure. Our patient was a 3-year-old boy who had posttraumatic hydrocephalus, and presented with peritoneal-tube transanal protrusion and abdominal pain. The perforation site, diagnosed at surgery, was in the terminal ileum, and the interval between the latest VPS and the subsequent perforation was 18 months. He underwent laparoscopic exploration for extracting the distal and proximal ends of the peritoneal tube from the anus and extracorporeally from the ileum, respectively, after which the ileal perforation was closed. The clinical characteristics and management of the seven patients with small-intestinal perforation and our patient were similar to those of the patients with VPS-induced bowel perforation in other locations.