Novel Insights from Clinical Practice Pediatr Neurosurg 2014–15;50:220–222 DOI: 10.1159/000430847

Received: March 16, 2015 Accepted after revision: April 21, 2015 Published online: June 5, 2015

Ventriculoperitoneal Shunt Tip as a Rare Cause for Recurrent Pain Episodes in a Child: Think Irritable Peritoneum Martin Poryo a Regina Eymann b Sascha Meyer c Departments of a Pediatric Cardiology, b Neurosurgery and c Pediatric Neurology, Saarland University Medical Center, Homburg/Saar, Germany

Established Facts • Ventriculoperitoneal (VP) shunt dysfunction (over- and underdrainage) may cause recurrent episodes of headache. • In severely neurologically disabled children with VP shunts, establishing an exact cause for recurrent pain episodes may be challenging.

Novel Insights • In addition to proximal catheter dysfunction, the distal end may lead to non-infectious painful episodes related to peritoneal irritation. • Repositioning of the distal part of the ventriculoperitoneal shunt will lead to prompt resolution of pain.

Key Words Hydrocephalus · Ventriculoperitoneal shunt · Children · Complication · Pain

VP shunt. Visceral irritation by a malpositioned VP shunt should be considered as a cause for recurrent pain in nonverbal children without other relevant clinical findings. © 2015 S. Karger AG, Basel

© 2015 S. Karger AG, Basel 1016–2291/15/0504–0220$39.50/0 E-Mail [email protected] www.karger.com/pne

Introduction

In cases of elevated intracranial pressure, ventriculoperitoneal (VP) shunting is an established treatment to regulate the drainage of cerebrospinal fluid (CSF) [1, 2]. However, this system may also lead to complications like blockage of CSF shunting or overdrainage of CSF, but also include other rare complications like catheter-related perforations of abdominal organs [3, 4]. These comDr. Martin Poryo Department of Pediatric Cardiology Saarland University Medical Center Kirrberger Strasse, DE–66421 Homburg/Saar (Germany) E-Mail martin.poryo @ uks.eu

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Abstract Ventriculoperitoneal (VP) shunting is an established treatment to regulate the drainage of cerebrospinal fluid (CSF) in posthaemorrhagic hydrocephalus. Several complications (e.g. blockage of CSF shunting, overdrainage, but also catheter-related perforation of abdominal organs, etc.) may occur and may lead to painful episodes, mostly headache, in these children. Here, we report on a 7-year-old child with recurrent painful episodes after revision of a VP shunt that subsided only after repositioning of the abdominal tip of the

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VP Shunt Tip as Cause for Recurrent Pain in a Child

Pediatr Neurosurg 2014–15;50:220–222 DOI: 10.1159/000430847

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Fig. 1. X-ray (anteroposterior view): the tip of the catheter is localized in the left epigastric region. Fig. 2. X-ray (lateral view): the catheter shows a ventral to dorsal course, and the tip is located near the diaphragm. Fig. 3. X-ray (anteroposterior view): after shortening the catheter by 12 cm, the tip is now located at the height of the iliac crest.

plications may lead to recurrent episodes of pain, mostly headache, but also abdominal pain in rare cases of perforation of abdominal organs. For the treating physician, it is often difficult to correctly interpret behavioural changes in non-verbal and developmentally delayed children who cannot express themselves adequately. Here, we report on a rare, catheter-related cause of recurrent pain in a child with VP shunting.

catheter irritated the peritoneum and capsule of the spleen during longer vertical position. Thus, the shunt was shortened by 12 cm whereby the position of the tip was relocated to the pelvic inlet (fig. 3). The procedure was uneventful, and during further observation self-mutilation behaviour and screaming fits improved significantly and eventually subsided, and the girl began to eat and drink in a normal way.

Comment

We report on a 7-year-old, former extremely premature, female neonate (25 weeks of gestational age). She suffered from grade 3 intraventricular haemorrhage requiring insertion of a VP shunt for posthaemorrhagic hydrocephalus. The further course was complicated by insufficient CSF shunting via the VP shunt requiring ventricular-atrial shunting. However, secondary to thrombotic complications, again a VP shunt was established at the age of 2 years, and recently a new, the third, VP shunt was inserted. After this last surgery, the girl was initially well for about 1 month but then exhibited recurrent screaming fits and tendencies for self-mutilation. Furthermore her eating and drinking behaviour worsened. The performed X-ray of the shunt (fig. 1, 2) as well as the cerebral magnetic resonance imaging study showed no new relevant pathologies. However, the ending of the VP shunt was seen in the left epigastric region adjacent to the spleen rather than being located in the Douglas pouch where it was positioned intra-operatively. Because of the described symptoms, which worsened while sitting upright for several hours, we hypothesized that the tip of the

References

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First of all, elevated intracranial pressure has to be excluded, when developmentally delayed, non-verbal children with VP shunts show clinical signs of pain like recurrent screaming fits and tendencies for self-mutilation. When cranial imaging studies (computed tomography, magnetic resonance imaging) are without relevant new pathological findings and conventional X-ray may demonstrate unusual positioning of the tip of the VP shunting system, visceral irritation by the shunt itself has to be considered. In more severe cases, this may even result in the perforation of abdominal organs by the catheter [3, 5]. To the best of our knowledge, this is the first case report in written form that describes a malpositioned VP shunt as a cause for recurrent painful episodes in a severely neurologically impaired child. We assume that this circumstance may be underestimated in children in whom no other pathology is found.

1 Reddy GK, Bollam P, Caldito G: Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus. World Neurosurg 2014;81:404–410. 2 Romero L, Ros B, Ríus F, González L, Medina JM, Martín A, et al: Ventriculoperitoneal shunt as a primary neurosurgical procedure in newborn posthemorrhagic hydrocephalus: report of a series of 47 shunted patients. Child Nerv Syst 2014;30:91–97.

Pediatr Neurosurg 2014–15;50:220–222 DOI: 10.1159/000430847

3 Rinker EK, Osborn DA, Williams TR, Spizarny DL: Asymptomatic bowel perforation by abandoned ventriculoperitoneal shunt. J Radiol Case Rep 2013;7:1–8. 4 Charalampoudis P: Right lower quadrant abdominal pain in a patient with prior ventriculoperitoneal shunting: consider the tip! Case Rep Med 2012;2012:1–2. 5 Thipphavong S, Kellenberger CJ, Rutka JT, Manson DE: Hepatic and colonic perforation by an abandoned ventriculoperitoneal shunt. Pediatr Radiol 2004;34:750–752.

Poryo/Eymann/Meyer

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Case Report

Ventriculoperitoneal Shunt Tip as a Rare Cause for Recurrent Pain Episodes in a Child: Think Irritable Peritoneum.

Ventriculoperitoneal (VP) shunting is an established treatment to regulate the drainage of cerebrospinal fluid (CSF) in posthaemorrhagic hydrocephalus...
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