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Endoscopic management of transanal protrusion of subdural peritoneal shunt in a child.

JPGN Volume 53, N The first case of transanal protrusion was reported in 1966 by Wilson and Bertran (20). Transanal protrusion of VP shunt S ubdural peritoneal shunts (SP shunts) are used in the management of chronic subdural collections. The basic objective is similar to that of ventriculoperitoneal shunts (VP shunts); namely, the excess fluid is drained into the peritoneal cavity and is absorbed. The equipment and techniques used in these 2 types of shunts are similar, which suggests similar complications may arise. Although there has been an extensive literature regarding VP shunts, there have been scant reports about SP shunts. Hence, the literature regarding VP shunts is incorporated in our case. Cases of bowel perforation have been reported in which anal protrusion of the distal part of the VP shunt was the initial presentation (1–15). Abdominal surgery was the approach used to manage most cases. Only a few cases reported in the literature were managed endoscopically. In 1996, Brown et al (1) reported the first case successfully managed by sigmoidoscopy, establishing this method to be an important option for uncomplicated cases. We report this case of anal protrusion of a SP shunt in a 30-month-old child managed by colonoscopy with a favorable outcome. A 30-month-old child with right SP shunt placed at 13 months of age because of an enlarged subdural space and increased head circumference presented to the hospital because of an extrusion of the shunt through the anus. He was in his usual state of health when approximately 12 cm of the shunt tubing was noted to be protruding from the child’s anus during defecation. The extruded shunt was cut at home and the child was brought to the emergency department. He was completely asymptomatic at the time of presentation. Physical examination, including a rectal examination, was unremarkable, with no tubing visible at the anus. He was admitted to the pediatric intensive care unit and placed on broad-spectrum antibiotics because of the concern of bowel perforation and possible peritonitis and shunt infection. His shunt was then externalized at the cervical level. Computed tomography scan of the abdomen showed the shunt entering the lumen of the transverse colon (Figs. 1 and 2), and hence an urgent unprepped colonoscopy was performed to visualize the shunt tubing in an attempt to remove it and assess possible bowel perforation. During colonoscopy, the shunt tubing was visualized in the stool in the colon (Figs. 3 and 4). The visualized mucosa appeared