Small Bowel Ischemia from Spontaneous Ventriculoperitoneal Shunt Knot Formation in a Pediatric Patient: A Case Report

Small bowel ischemia caused by spontaneous ventriculoperitoneal (VP) shunt knot formation is a rare complication in the pediatric population. Clinical presentation may range from symptoms of malformation to bowel obstruction with and without gangrene. We report the surgical management of spontaneous VP shunt knot formation with preservation of bowel and salvage of the shunt. We present a case of small bowel ischemia in a 5-year-old with a history of VP shunt for hydrocephalus who presented with symptoms of bowel obstruction. A head computed tomography (CT) was found to have no evidence of hydrocephalus, however, abdomen and pelvis CT was concerning for ischemic bowel. An emergent exploratory laparotomy was performed and identified spontaneous knot formation of the VP shunt around the base of the mesentery, causing small bowel ischemia of the mid to distal ileum. The abdomen was left open and subsequently closed within 24 hours without need for bowel resection. In patients with VP shunts and acute-onset gastrointestinal symptoms, small bowel ischemia from a knotted VP shunt is a consideration. A high index of suspicion and emergent intervention can prevent permanent intestinal injury.