Transanal Extrusion of Ventriculoperitoneal Shunt Tubing in a Pediatric Patient

Gastrointestinal perforation is a rare but potentially life-threatening complication of ventriculoperitoneal (VP) shunts. Patients may have minimal or no abdominal symptoms despite bowel perforation and the risk of ascending central nervous system infection.

A 12-year-old boy with hydrocephalus treated with a VP shunt presented to the Emergency Department after his parents discovered a segment of rubber tubing in his stool. He was afebrile, well appearing, neurologically at baseline, and without abdominal pain, vomiting, or symptoms of shunt malfunction. His abdominal examination was benign. A shunt series demonstrated an intact right-sided VP shunt and retained catheter fragments from a previously disconnected left-sided shunt, without an apparent abnormality of the functioning shunt. Despite the reassuring examination and radiographic findings, passage of shunt tubing per rectum raised concern for bowel perforation. Broad-spectrum antibiotics were initiated, and urgent surgical exploration demonstrated that the functioning right-sided VP shunt had perforated the colon with formation of a fistulous tract. The shunt was externalized and the colonic defect repaired. Cerebrospinal fluid cultures subsequently grew gram-negative organisms, requiring complete shunt removal, external ventricular drainage, and prolonged antimicrobial therapy.Why Should an Emergency Physician Be Aware of This?: Transanal extrusion of VP shunt tubing should prompt immediate concern for bowel perforation even in an asymptomatic, well-appearing patient with reassuring initial imaging. Prompt recognition, broad-spectrum antimicrobial therapy, and urgent neurosurgical and surgical consultation are essential because bowel perforation may permit ascending infection resulting in ventriculitis, meningitis, or sepsis.