Gastrointestinal Imaging • Original Research

Chung et al. CT of Ventriculoperitoneal Shunts Gastrointestinal Imaging Original Research

Downloaded from www.ajronline.org by 110.138.163.192 on 06/20/13 from IP address 110.138.163.192. Copyright ARRS. For personal use only; all rights reserved

Intraabdominal Complications Secondary to Ventriculoperitoneal Shunts: CT Findings and Review of the Literature
Jae-Joon Chung1 Jeong-Sik Yu1 Joo Hee Kim1 Se Jin Nam1 Myeong-Jin Kim 2
Chung JJ, Yu JS, Kim JH, Nam SJ, Kim MJ

Keywords: abdominopelvic CT, cerebrospinal fluid, hydrocephalus, peritonitis, pseudocyst, ventriculo­ peritoneal shunt DOI:10.2214/AJR.09.2463 Received January 27, 2009; accepted after revision April 12, 2009. Supported by a research grant from Yonsei University College of Medicine for 2008.
1 Department of Radiology and Research Institute of Radiological Science, Gangnam Severance Hospital, Yonsei University College of Medicine, 612, Eunjuro, Gangnam-gu, 135-720 Seoul, Korea. Address correspondence to J. J. Chung (jjchung@yuhs.ac). 2 Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.

OBJECTIVE. The purpose of our study was to evaluate the abdominopelvic CT findings of various intraabdominal complications secondary to ventriculoperitoneal shunts for hydrocephalus and to review the literature. MATERIALS AND METHODS. The CT images of 70 patients (33 men and 37 women; mean age, 48.5 years) who underwent ventriculoperitoneal shunt placement and abdominopelvic CT because of shunt-related abdominal symptoms were reviewed retrospectively. CT images were analyzed with regard to the location of the shunting catheter tip; site, size, wall, and septa of localized fluid collection; peritoneal thickening; omentomesentery infiltration; abscess; bowel perforation; abdominal wall infiltration; and thickening of the catheter track wall. RESULTS. The mean period between the last ventriculoperitoneal shunting operation and CT was 11 months (range, 1 week to 115 months), and the mean number of ventriculoperitoneal shunting operations undergone was 1.4 (range, 1–6). A total of 76 ventriculoperitoneal shunting catheters were introduced in 70 patients: 64 patients had a unilateral catheter inserted and six patients had bilateral catheters inserted. Sixteen patients (22.9%) were pathologically diagnosed with ventriculoperitoneal shunt–related complications: 11 cases (15.7%) of shunt infection, six cases (8.6%) of CSF pseudocyst, four cases (5.7%) of abdominal abscess, three cases (4.3%) of infected fluid collection, and one case (1.4%) of bowel perforation. Microorganisms were cultured from the tip of the shunting catheter or peritoneal fluid in 11 patients (15.7%). CONCLUSION. On abdominopelvic CT, various intraabdominal complications secondary to ventriculoperitoneal shunt were shown, of which, shunt infection was the most common, followed by CSF pseudocyst, abscess, and infected fluid collection. lacement of a ventriculoperitoneal shunt is the most common operation performed in the treatment of hydrocephalus. Intraabdominal complications after ventriculoperitoneal shunt placement are most commonly located near the peritoneal end of the shunt catheter; more than 50% of patients require shunt revision [1, 2]. The most common complications have been infection of the shunt, malfunction due to blockage, disconnection, migration, and equipment failure, which are related to extraperitoneal retraction of the catheter, development of an incisional hernia, subcutaneous collection of CSF, and peritoneal pseudocyst formation due to lowgrade infection followed by wrapping by the omentum [2–4]. Other complications reported in the literature include intestinal perforation, CSF ascites, inguinal hernia, and intestinal volvulus [5–7]. These complications

P

AJR 2009; 193:1311–1317 0361–803X/09/1935–1311 © American Roentgen Ray Society

may manifest as either local abdominal signs or increased intracranial pressure. Shunt infection remains a frequent and potentially fatal complication of CSF diversion. Therefore, a key issue in the treatment of these complications is early and correct diagnosis of intraabdominal complications by CT, MRI, sonography, or abdominal radiography. There have been several case reports about various abdominal complications that can occur after ventriculoperitoneal shunting operations [8–11]. The purpose of this study was to evaluate the CT findings of various intraabdominal complications secondary to ventriculoperitoneal shunt placement for hydrocephalus and to review the literature. Materials and Methods
This retrospective study was approved by our institutional review board, and the requirement for

AJR:193, November 2009

1311

age range.9% of all patients) of whom were finally diagnosed with acute appendicitis. omentomesentery infiltration. shunt revision was performed. B. For personal use only. and hematochezia (n = 1). Twelve (70. 12 cases of subarachnoid hemorrhage and intraventricular hemorrhage (IVH). right paracolic gutter (RPG). bowel perforation. four cases of IVH. two cases of congenital disease. three patients underwent CT for renal or ureteral stones. peritoneal contrast enhancement. and abdominal wall. and one case of subdural hematoma. five patients had no recorded clinical information for an abdominopelvic CT scan.org by 110. six had RLQ pain that was initially diagnosed as acute appendicitis. two patients underwent CT for gallstones. given by an automatic injector at 3–4 mL/s. abdominal wall mass. all rights reserved Results Abdominopelvic CT was performed in 70 patients for complaints of varying abdominal symptoms.192. Subsequently. An attending abdominal radiologist retrieved the images from a hospital archiving system and conducted a preliminary review of the CT images of the 100 patients. with a 7-mm collimation and a 7-mm reconstruction interval. ventriculitis with suspected shunt infection (n = 5). the presence of walls or septa in the localized fluid collections. advanced hydrocephalus because of shunt malfunction. 3-minute delayed equilibrium phase images were obtained. B 1312 AJR:193. More caudal CT image shows pericystic irregular fluid collections (arrows ) in abdominal wall. five cases of hypertensive ICH and IVH. localized abdominal pain (n = 17). and falling injury [n = 1]). and intraperitoneal free air. bowel-wall thickening and contrast enhancement. mean age. and there was no growth of microorganism from catheter tip. abdominal wall infiltration. We reviewed the medical records of all patients who underwent abdominopelvic CT after ventriculoperitoneal shunt placement from January 2001 to June 2008. palpable abdominal mass (n = 2). Copyright ARRS. pelvic cavity (below acetabular roof). 48.Chung et al. Downloaded from www.163. 2–75 years.ajronline. After exclusion of the aforementioned 30 patients. aggravated hydrocephalus due to shunt malfunction (n = 9). evaluation of hypertension [n = 2]. This patient complained of aggravated headache because of advanced hydrocephalus from shunt malfunction. The locations of intraperitoneal fluid collections were divided into right upper quadrant (RUQ). Among the patients reviewed. thickening of the catheter track wall. two cases of ICH after infarct. Inclusion criteria for the study included abdominopelvic CT with previous ventriculoperitoneal shunt placement and abdominal symptoms such as diffuse or localized abdominal pain. two cases of meningitis. fever with abdominal symptoms. two cases of vascular ICH and IVH. Schering). After IV administration of 120–150 mL of nonionic iodinated contrast medium (iopromide. Ultravist 300. pus discharge from the operation site (n = 1). The medical records of 100 consecutive patients were reviewed.192 on 06/20/13 from IP address 110. Among the 12 patients with lower abdominal pain. three patients underwent CT for urinary tract infection. ventriculitis because of shunt infection. informed consent was waived. November 2009 . left paracolic gutter (LPG). One abdominal radiologist with 14 years of experience reviewed all the abdominopelvic CT images. Causes of hydrocephalus were subarachnoid hemorrhage and intraventricular hemorrhage. six cases of postoperative hemorrhage. prolonged diarrhea. 11 cases of traumatic intracerebral hemorrhage (ICH) and IVH. a total of 70 patients (33 male and 37 female. midabdomen (paraumbilical area). six cases of postoperative ischemic change.138. such as diffuse abdominal pain (n = 25). The causes of hydrocephalus in the 70 patients were 14 cases of primary or secondary brain tumors. A Fig. two (2. subphrenic free air (n = 1). Two cases of congenital diseases were from a case of congenital hydrocephalus and a case of ArnoldChiari malformation. and hematochezia. All scanned images were sent to the PACS for interpretation. left upper quadrant (LUQ). five patients underwent ventriculoperitoneal shunt removal just before the CT for shunt malfunction. Two cases of vascular ICH and IVH were from a case of moyamoya disease and a case of arteriovenous malformation (AVM). 1— 51-year-old woman with large pseudocyst in abdominal wall. A. three cases of tumor seeding. prolonged diarrhea (n = 3). a total of 30 were excluded for the following reasons: seven patients had no specific abdominal symptoms (staging workup for underlying cancer [n = 4].138.6%) of the 17 patients with localized abdominal pain complained of lower abdominal pain. abscess. four patients underwent CT for evaluation of percutaneous endoscopic gastrostomy tube placement.5 years) were enrolled in this study. Smoothly compressed abdominal wall muscle is noted. right lower quadrant (RLQ).163. focusing on the site and size of localized fluid collection. pus discharge from the operation site. Contrast-enhanced abdominopelvic CT scan shows about 13 × 10 cm pseudocyst in subcutaneous layer of right anterior abdominal wall with internal ventriculoperitoneal shunt catheter. peritoneal thickening. and one patient underwent CT for voiding difficulty. The window for abdominopelvic CT was from 2 cm above the right hemidiaphragm to 2 cm below the symphysis pubis. fever with vague abdominal symptoms (n = 6). left lower quadrant (LLQ).

19 cases (27.163. which included 11 cases (15. More cephalic CT image shows inflammatory fatty infiltration in subcutaneous layer of right midabdominal wall with adjacent skin thickening. Shunt revision was performed and Staphylococcus aureus grew from tip of shunt catheter.0%) showed internal septa within the fluid collection. Among them. November 2009 1313 . Adjacent small-bowel loops show mild wall thickening with mesenteric haziness and fluid collections in both paracolic gutters. four cases (5. RLQ (n = 3). CT was performed because of abdominal pain.9%) were histopathologically diagnosed with shunt-related complications.7%) of abdominal abscess (Fig. 1–6).138.9%) of peritoneal thickening. In the 70 patients. all rights reserved Of the 70 patients. and the mean number of ventriculoperitoneal shunting operations undergone was 1. mid­ abdomen (n = 5). Eighteen patients (25.163.192 on 06/20/13 from IP address 110.4%) of bowel perforation.4 (range. A. B. The locations of the 87 localized fluid collection sites were the pelvic cavity (n = 55). 1). Seven cases (10.ajronline. pelvis (n = 2).6%) of omentomesentery infiltration (Figs.org by 110. 1 week to 115 months). RUQ (n = 1).7%) of shunt infection (Fig. Cause of hydrocephalus was postoperative intraventricular hemorrhage for arteriovenous malformation and patient complained of localized abdominal pain in abdominal LLQ. AJR:193. of which 47 patients (67.9%) had three fluid collecting sites. 5). There was no growth of microorganisms from catheter tip and shunt externalization was performed. 6) of pseudocyst caused small-bowel obstruction secondary to wrapped mesentery at the catheter tip within 5 days of ventriculoperitoneal shunt placement.138. six patients had bilateral ventriculoperitoneal shunting catheters placed. three cases of pseudocyst. LPG (n = 4). and LLQ (n = 1). six cases (8.6%) of CSF pseudocysts. Among these. Contrast-enhanced abdominopelvic CT scan shows localized dirty infiltration in omento­ mesentery of abdominal left lower quadrant (LLQ) with adjacent peritoneal thickening and minimal fluid collection. 34 cases (48. One case (Fig.1%) of peritoneal enhancement. RPG (n = 16). 16 (22.6%) of CSF pseudocyst formation (Fig.3%) had two fluid collecting sites. 12 (17. 2 and 5). Of the six cases (8. Contrast-enhanced abdominopelvic CT scan shows 11 × 6 cm pseudocyst in abdominal right lower quadrant with enhanced wall and internal shunt catheters (arrows ). and abdominal wall (n = 1) (Fig. A B Fig. Three cases of infected fluid collection were diagnosed by sonographically guided aspiration of fluid.1%) had one fluid collecting site. 2— 33-year-old man with localized omentomesentery infiltration. The locations of the six CSF pseudocysts were the RLQ (n = 3). and two (2. Downloaded from www.7%) showed a wall of fluid collection. five were located in the peritoneal space and one was located in the abdominal wall. There were 30 cases (42. 3—20-year-old man with intraperitoneal pseudocyst and inflammatory infiltration in abdominal wall. In the 70 patients. 17 (24. Copyright ARRS. The mean period between the last ventriculoperitoneal shunting operation and abdominopelvic CT was 11 months (range. One patient with subphrenic free air was diagnosed with peritonitis secondary to a 5-mm bowel perforation in the transverse colon due to the shunting catheter. 76 ventriculoperitoneal shunting catheters were introduced: 64 patients with a unilateral catheter and six patients with bilateral catheters.1%) of which showed contrast enhancement of the wall. Causes of hydrocephalus were traumatic hemorrhage and postoperative ischemic change.3%) of infected localized fluid collection (Fig. 2). and one case (1. There were 46 right ventricle–origin shunting catheters and 30 left ventricle–origin shunting catheters. 3). as well as six CSF pseudocysts were found. 4). Ventriculoperitoneal shunt catheter (arrows ) is noted within localized infection area. 87 localized fluid collection sites. LUQ (n = 1). Small amount of fluid collection is also seen in both paracolic gutters. Fig. one patient had fluid collections in both paracolic gutters. three cases (4. all four cases of abscess. and two cases of infected localized fluid collection coexisted in the patients with shunt infection. For personal use only. abdominal wall (n = 1).CT of Ventriculoperitoneal Shunts Ventriculitis was suspected in five patients because of findings on brain CT or MRI examinations that were performed for acute and persistent headache or increased intra­ cranial pressure.192.

0%). and one case of gram-negative cocci. and a third ventriculostomy [13]. resulting in associated complications that can cause considerable morbidity and possibly death [5].163. exploratory laparotomy (n = 2). A. In 10 patients. 15]. Discussion The use of the peritoneal cavity for CSF absorption in ventriculoperitoneal shunting was first introduced in 1908 by Kausch [12]. subcutaneous collection of CSF. one case of Acinetobacter baumannii. The most common distal ventriculoperitoneal shunt complications include shunt infection. with fluid collections in right paracolic gutter and mesentery. 16–20]. one case of Micrococcus species. stomach.Chung et al. cerebrospinal–enteric fistula. migration of the catheter into the pleural cavity and heart. 4—14-year-old boy with intraperitoneal abscess. Contrastenhanced abdominopelvic CT scan shows 3 × 1 cm lentiform-shaped low-density lesion (arrows) with rimlike enhancement noted in left anterior peritoneal cavity with adjacent peritoneal thickening. all rights reserved four cases (5.4%) of bowel perforation. Downloaded from www. removal of the catheter (n = 2). November 2009 . catheter disconnection. bladder. 22] include bowel obstruction secondary to adhesion. vagina.192.7%) of abscess. intestinal volvulus [6]. External drainage tube was inserted for treatment. and vomiting. For the treatment of ventriculoperitoneal shunt–related abdominal complications in the 16 patients (22. The peritoneal cavity is preferable to the pleural cavity for insertion or reinsertion of the shunt [6]. Micrococcus species grew from tip of shunt catheter. Nonenteric viscus perforations also can occur and can involve multiple organs. Obstruction of the distal catheter must be treated as an emergency because it can lead to a significant increase in intracranial pressure. and extraperitoneal retraction of the catheter through the mouth [10]. Other less-common abdominal complications [21. untreatable CSF ascites. Shunt catheter was removed. anus [11].138. A B Fig.9%) of bowel-wall thickening. Fig. uterus. 3). one case of Pseudomonas aeruginosa. and development of an incision hernia [8–11.ajronline. Causes of hydrocephalus were subarachnoid hemorrhage and intraventricular hemorrhage.138. shunt externalization and antibiotic therapy (n = 2). one case of vancomycin-resistant enterococci. 38 cases (54. peritoneal pseudocyst. This lesion was confirmed as abscess by percutaneous needle aspiration.9%) were histopathologically diagnosed with shunt-related complications. mesenteric pseudotumor. and conservative treatment (n = 1). or scrotum. umbilicus [4]. Contrast-enhanced abdominopelvic CT scan shows large amount of ascites with thickened and enhanced peritoneum (arrows ) with ventriculoperitoneal shunt catheter in left lower abdomen. one case (1. The most common causes of shunt malfunction are catheter obstruction and infection.org by 110. B. For personal use only. or urethra. 5— 67-year-old woman with intraperitoneal infected fluid collection. one case of gram-positive cocci. a lumboperitoneal shunt. subphrenic abscess.9%). The following microorganisms grew in 11 patients (15. there was no growth. CT was performed because of suspicion of shunt malfunction. such as the gallbladder. CT was performed because of abdominal pain. 16 patients (22. and Pseudomonas aeruginosa grew from aspirated abscess fluid. sonographically guided percutaneous drain tube insertion (n = 2). the following were used: antibiotic therapy only (n = 4). nine cases (12.7%): five cases of Staphylococcus aureus. Two shunt catheters are noted in both sides of abdominal wall with distal catheter near descending colon. Dirty fatty infiltration is also seen in omentomesentery of right midabdomen. In our study. 1314 AJR:193. Other shunting techniques have since been used and include a ventriculoatrial shunt. bowel perforation.3%) of abdominal wall infiltration (Fig.192 on 06/20/13 from IP address 110.0%) of thickening of the catheter track wall in the abdominal wall. More cephalic CT image shows loculated fluid collections with thin wall in both sides of midabdomen. and seven cases (10. nausea. laparotomy and drainage (n = 1). The incidence of ventriculoperitoneal shunt– related abdominal complications has been reported to be from 5% to 47% [14. liver.163. Copyright ARRS. shunt revision (n = 2). Specimen cultures from the peritoneal tips of the shunt catheter or intraperitoneal fluid were obtained in 21 patients (30. Cause of hydrocephalus was congenital Arnold-Chiari malformation.

Peritoneal fluid is either absent or present in only a small amount in patients with normally functioning ventriculoperitoneal shunts. a peritoneal cyst. and tissue reaction against tubing material and CSF protein [20] have been known to impair the absorption of CSF and to have a role in pseudocyst formation.6%) of pseudocyst were detected. The time from the last shunting procedure to the development of an abdominal pseudocyst ranges from 3 weeks to 5 years [16]. Coley et al. distention. it has been reported that 7% of ventriculoperitoneal shunt infections are caused by Escherichia coli [17]. and 70–80% of patients require at least one revision at some point in their lives [16]. More cephalic CT image shows considerably more distended small-bowel loops with internal bowel contents and air–fluid level. In our study. or subphrenic or lesser sac loculation [8]. However. or the parietal peritoneum [8]. B Malfunction of the ventriculoperitoneal shunt after initial placement occurs in approximately 25–35% of patients at 1 year [23]. suggesting mechanical bowel obstruction. allergic reactions to immunization [30]. The most common presentation of an abdominal CSF pseudocyst in children is elevated intracranial pressure and abdominal pain. Shunt infection remains a frequent and potentially fatal complication of CSF diversion. The infection and subsequent high levels of CSF protein.org by 110. or vomiting. differentiation of ascites from the aforementioned cystic lesions may not be possible.192. For personal use only. Shunt catheter (arrow ) is seen just below peritoneum. The CSF draining into these sheaths may produce large intraabdominal fluid-filled cysts [8]. with an infection rate of 7% over the same period. with a reported incidence of less than 1. nausea.192 on 06/20/13 from IP address 110. shunt infection was confirmed by bacterial culture in 11 patients (15. Cochrane and Kestle [24] reported the initial shunt failure rate to be 31% at 6 months for experienced surgeons.138. six cases (8. the serosal surface of solid organs. an omental cyst. and approximately 70% of shunt infections occur within 2 months after shunt placement [13.163. such as abdominal pain. Copyright ARRS. the mean period between the last ventriculoperitoneal shunting operation and abdominopelvic CT was 11 months. CSF pseudocysts can be differentiated from ascites by their characteristic displacement of the bowel gas pattern on abdominal films and by the absence of shifting dullness [8].7%).3%) had an interval of less than 11 months.CT of Ventriculoperitoneal Shunts Downloaded from www. Laparoscopy confirmed small-bowel obstruction caused by adherent pseudocyst secondary to wrapped mesentery at catheter tip. One of these eight patients underwent laparotomy because of small-bowel obstruction caused by smallbowel mesentery wrapping around the catheter tip and pseudocyst. [31] reported that although the sonographically guided percutaneous aspiration of CSF pseudocyst was not curative. 27]. In our study. CSF loculation may present as recurrent ascites. November 2009 1315 .ajronline. Contrast-enhanced abdominopelvic CT scan shows approximately 6 × 5 cm pseudocyst in abdominal right lower quadrant with adherent and distended neighboring small-bowel loops. performance of this procedure to alleviate the acute symptoms followed by elective shunt revision is a feasible alternative to the traditional treatment approach and could be helpful to limit radiation exposure to patients who were likely AJR:193. 6— 48-year-old man with intraperitoneal pseudocyst causing small-bowel obstruction. The most common organism was S. The most common intraabdominal response to infection is sheathing of the peritoneal catheter. with a reported incidence of 5–47% [14. An abdominal CSF pseudocyst was first described by Harsh [28] in 1954. 52 patients (74. Although sonography and CT can accurately localize abdominal fluid collections. 25]. Therefore.138. No microorganism grew from pseudocyst fluid. fine-needle aspiration of the localized CSF collections under sonographic or CT guidance should be performed to increase the diagnostic yield. Hahn et al. Cause of hydrocephalus in this patient was chondrosarcoma in skull base. 15]. aureus. In our study. whereas local abdominal signs. Among these 52 patients. There has been a reported case of pseudocyst formation 10 years after ventriculoperitoneal shunt placement.163. predominate in adults [8]. The CSF pseudocyst can either move freely within the peritoneal cavity or adhere to loops of small bowel. 26]. The wall of the pseudocyst is composed of fibrous tissue or an inflamed serosal surface without an epithelial lining and is filled with CSF and debris [8. liver dysfunction [19]. and CT was performed because of abdominal pain. Peritoneal CSF pseudocyst formation is an unusual complication. all rights reserved A Fig. A.5% [8. [29] reported that infection was the most prominent cause of pseudocyst formation (80%) and emphasized that all cases of abdominal pseudocysts should be considered to be caused by infection until proven otherwise. Ventriculoperitoneal shunt catheter was removed and reintroduced into another site. and the time interval between the last shunting operation and abdominopelvic CT ranged from 5 days to 25 months. B. eight underwent abdominopelvic CT within 1 week because of abdominal symptoms.0–4.

13:352–354 15. axial location of shunt tip and adjacent abnormal findings. Turner R. Dave S. however. et al. Laparoscopic management of distal ventriculoperitoneal shunt complications. Trans-anal protrusion of ventriculo-peritoneal shunt catheter with silent bowel perforation: report of ten cases in children. 54:388–396 8. of which 12 cases (17. one case (1. 15:577–578 7.1%) showed wall enhancement and seven (10. Nanda A. Rosenblatt S. and intraperitoneal free air can be seen. Pierre-Kahn A. abscess. This complication can lead to fatal meningeal infection when not recognized early. Hauerberg J. Frequency and causes of shunt revisions in different cerebrospinal fluid shunt types. The overall mortality rate of bowel perforation is nearly 15% in shunted patients [26]. histopathologic diagnoses via fluid aspiration were available in only a few cases. Bal RK. Sáenz EV.163. The risk of ventriculoperitoneal shunt– related complications varies with the use of prophylactic antibiotics. India: Modern Publishers.7% of microorganisms being cultured. In: Gupta DK. Recently.0%) showed internal septa. Sells CJ. Harjai MM. catheter track. The localized peritoneal fluid collections with contrast-enhanced walls or internal septa were not analyzed for possible infection or localized peritonitis. On sonography. and a subsequent abdominopelvic CT and exploratory laparotomy were performed. 11:167–170 4. and experience of the operating surgeon. Gupta DK. Khaldi M.. Baskaya MK.1–0. Pediatr Surg Int 2002. November 2009 . The use of laparoscopy in the diagnosis and treatment of abdominal complications of ventriculoperitoneal shunts in children. silicon allergy. Clinicians must be vigilant in their assessment for the presence of the following clinical conditions in shunted patients: meningitis or ventriculitis caused by an enteric microorganism (e. Renier D. displaced bowel gases. Abdominal complications of ventriculoperitoneal shunts in children: 65 cases. Messerer M. pneumocephalus. Acta Neurochir (Wien) 1995. On contrast-enhanced CT or MRI. soft-tissue mass of pseudocyst. to have significant exposure during their lives.138. Gram-negative CSF shunt associated infections. has been implicated in the breakdown and perforation of the bowel wall [18]. Zavala MJ. et al. et al. sonography. Indian J Surg 2004. 10:353–355 10. 25:17–21 16. 18 cases (25. Porreca A. Bowel perforation should be suspected in cases of shunt infection by gram-negative bacilli.7% of cases [9]. Gangemi M. Borgbjerg BM. Transoral protrusion of a peritoneal catheter: a rare complication of ventriculoperitoneal shunt. The number of pathologically confirmed cases was small. 87:709–796 13. The imaging techniques for early detection of intraabdominal complications secondary to ventriculoperitoneal shunt include radiography. occurring in less than 0. all rights reserved 1316 AJR:193.163. New Delhi. Abdominal CSF pseudocyst in a patient with ventriculo-peritoneal shunt. among which nearly half are diagnosed after removal of the catheter. Ramzan A. Acharya R. Surg Endosc 2008. or abdominal pain [22]. Hydrocephalus. Singh S. 136:189–194 2. Blount JP. Chir Pediatr 1984. Arch Kiln Chir 1908. Sharma AK. Gjerris F. Haines SJ. Ingale HA. Luciano M. E. 44:169–171 11. J Laparoendosc Adv Surg Tech 2001. Shurtleff DB. In our study. If infection is present. References 1. CT. Diyora BD. the location of the shunt tip. Complications Downloaded from www. Ramachandran CS. Chand B. Berhouma M. Die Behandlung des Hydrocephalus der kleinen Kinder. coli) and abdominal symptoms. Lortat-Jacob S. Culture of the tip of the peritoneal catheter was reported to be more sensitive than culture of the CSF [8].Chung et al. Once the shunt tip is removed. Recognition of these facts and consequent changes in treatment have resulted in a steady improvement in the outcomes of patients undergoing ventriculoperitoneal shunt placement [33]. Pediatr Surg Int 2007. or omentomesentery was diagnosed only according to the findings on CT images of fatty infiltration or a thick and enhanced catheter track wall and were not proven histologically. On radiography. prolonged unexpected diarrhea with sterile cultures. The study is retrospective.138. Nevertheless. Pandey AK. the CSF had to be diverted to other cavities because of either recurrence of the cysts or failure of the peritoneum to absorb fluid [27]. septa. subclinical shunt infection. Pediatr Surg Int 1998. we believe that familiarity with the broad spectrum of ventriculoperitoneal shunt complications will enhance the role of radiologists in the management of intraabdominal complications [7]. Textbook of neonatal surgery. Copyright ARRS. the peritoneal thickening. 59:614–618 3. 23:575–580 12. The formation of a CSF pseudocyst is a poor prognostic sign for the usefulness of the peritoneal cavity for shunting [32]. omentomesentery infiltration. 18:171–172 5. 22:1866–1870 6. Mamidanna R. In our study. Laparoscopic management of abdominal complications in ventriculoperitoneal shunt surgery. and localized extraluminal air densities because of bowel perforation can be well evaluated. Tech Coloproctol 2006. 30 cases were excluded for various reasons. Loeser JD. There are a few limitations to this study. Borgesen SE. especially children.ajronline. Albeck MJ.7%) showed a wall of fluid collection. Shrivastava DK. Nfonsam V. Budhwani KS. however. 66:360–363 9. Román CB. Martinez Hernández-Magro P. Kausch W. showing transverse colon perforation by the catheter tip. Houisssa S. Pediatrics 1977. Patients with myelome­ ningocele or congenital hydrocephalus may be more prone to bowel perforation because of neurogenic weakness of the bowel wall from deficient innervations [7]. the internal content.org by 110. 29]. Although previous abdominal pseudocyst formation and peritonitis are not contraindications to subsequent peritoneal shunting in some reports [19.192. Wani MA. Infiltration or infection of the abdominal wall. CT may be more useful for the exact diagnosis of complicated intraabdominal abnormalities. Intestinal volvulus: a rare complication of ventriculoperitoneal shunt. which may result in a foreign body–like reaction. and increased protein content in the CSF [11]. ed. Bowel perforation is a rare complication of ventriculoperitoneal shunt placement. Pediatr Surg Int 1999. the pseudocyst gradually collapses because there is no secretory epithelium present in the cyst [3].192 on 06/20/13 from IP address 110. Surg Neurol 2000. size and condition of the patient. 2000:434–450 14. Protrusion of a peritoneal catheter through the umbilicus: an unusual complication of a ventriculoperitoneal shunt. Possible causes of bowel perforation include the sharp tip of the shunting catheter. Ghritlaharey RK. Campbell JA. bowel-wall thickening and contrast enhancement. Among these techniques. Singh P. Bowel perforation can occur immediately after shunt placement or months or years later. Spontaneous bowel perforation after ventriculoperitoneal shunt surgery: case report and a review of 45 cases. Sayal PP. Sathyanarayana S. Esposito C. with only 15.4%) of bowel perforation initially presented with subphrenic free air. and wall thickness of pseudocysts can be observed well. For personal use only. A high degree of suspicion and careful clinical and radiologic examinations could help diagnose and treat ventriculoperitoneal shunt–related complications before they progress to more serious conditions.g. Wylen EL. such as prolonged unexplained diarrhea and fever [10]. therefore. the pseudocyst wall should be excised and the peritoneal shunting catheter removed [8]. Pediatr Neurosurg 2008. and MRI. Colonic perforation as a complication of ventriculoperitoneal shunt: a case report. Wani AA.

4:633–656 17. all rights reserved F O R YO U R I N F O R M AT I O N Mark your calendar for the following ARRS annual meetings: May 2–7. Amendola BE. 43:476–480 28. Colonic perforation by ventriculoperitoneal shunt tubing: a case of suspected silicon allergy. Harsh GR. 55:1–3 22. Kumar MV. 8:469–472 20. BC. 2010—Manchester Grand Hyatt San Diego. Paddon AJ. Murakami JW. Walters BC. Abdominal CSF pseudocyst in patients with ventriculo-peritoneal shunts: report of fourteen cases and review of literature. Neurosurg Clin N Am 1993. Hendrick EB. For personal use only. 127:73–78 21. J Neurol Neurosurg Psychiatry 1972. Steinhardt G. Wildbrett P. Coley BD. Keller IB.138. Engelhard H. Shirazi KK. 12: 75–79 30. 52: 347–353 24.ajronline. Fischer EG. CA May 1–6. Acta Neurochir (Wien) 1994. J Neurosurg 1975. Amendola MA. 2011—Hyatt Regency Chicago. Llewellyn RC.192. Hahn JF. San Diego. Oh A. Copyright ARRS. Yu LM. Canada April 14–April 19. Sonographically guided aspiration of cerebrospinal fluid pseudocysts in children and adolescents. Lee T. 2012—Vancouver Convention Center. Parry SW. Kestle JR. J Neurosurg 1954.org by 110. Heidecke V. Schuhmacher JF. J Pediatr Surg 1992. Cerebrospinal fluid ascites: a comparison of a ventriculoperitoneal shunt. Cochrane DD. Elton S. The influence of surgical operative experience on the duration of first ventriculoperitoneal shunt function and infection. 35:474–476 31. Fichten A. 15:518 27. IL April 29–May 4. Knotting of distal ventriculoperitoneal shunt tubing. J Neurosurg 1969. The risk of abdominal operations in children with ventriculoperitoneal shunts. Shunt revision for asymptomatic failure: surgical and clinical results. 38:295–301 25. Hahn YS. Vancouver. Vinchon M. AJR 2004. Latchaw JP Jr. Laparoscopic repositioning of a ventriculoperitoneal catheter tip for a sterile abdominal cerebrospinal fluid (CSF) pseudocyst. Abdominal pseudocysts and ascites formation after ventriculoperitoneal shunt procedures: report of four cases. Washington. 31:441–444 33. 2013—Marriott Wardman Park Hotel. Neurosurgery 2003.163. Surg Neurol 1998. Indian J Pediatr 2005. November 2009 1317 . 72:843–847 26. Shunt revision in hydrocephalus. Delestret I. Horton D. 146:323–326 23. 183:1507–1510 32. Tracy T Jr. Dean DF.192 on 06/20/13 from IP address 110. 60:1014–1021 18. Radiology 1983. Pediatr Neurosurg 2003. Abdominal CSF pseudocyst: clinical features and surgical management. Burkert W. Peritoneal shunt for hydrocephalus utilizing the fimbria of the fallopian tube for entrance to the peritoneal cavity. Schobess A. Neurosurgery 1981. Shillito J Jr. Pittman T.163. Surg Endosc 2001. 27:1051–1053 Downloaded from www. J Neurosurg 1984. Weber TR. Pediatr Neurosci 1985–1986.CT of Ventriculoperitoneal Shunts in ventricular cerebrospinal fluid shunting. Rainov N.138. Hoffman HJ. Large abdominal cysts: a comparison of peritoneal shunts: report of three cases. Schaefer IK. Cerebrospinal shunt infection: influences on initial management and subsequent outcome. Singh V. Brodley JS. Clin Radiol 2000. Kumar R. Williams D. Chicago. Goodrich J. DC AJR:193. Golub R. Humphreys RP. 11: 284–294 29. Shiels WE II. Unusual abdominal complications of ventriculo-peritoneal shunts. Chandler WF. McLone DG. Agha FP. Brownlee JD. Intraperitoneal pseudocyst associated with peritoneal shunt. 49:21–24 19. Hogan MJ. Dhellemmes P.