Abdominal Complications of

Ventriculoperitoneal Shunts in Children

Brian D. Coley, MD,* and Edward J. Kosnik, MD†

Ventricular peritoneal cerebrospinal fluid shunting has become a common pediatric neu-
rosurgical procedure over the last 40 years. While invaluable for these patients, shunts are
prone to complications, especially in children. Abdominal complications are often second-
ary to infection and its complications, and may be difficult to recognize in these medically
complex children. Imaging is often required, but the findings may be subtle and require an
appreciation of the spectrum of possible abnormalities. This article reviews the imaging
findings present with abdominal shunt complications.
Semin Ultrasound CT MRI 27:152-160 © 2006 Elsevier Inc. All rights reserved.

A ttempts at cerebrospinal fluid (CSF) ventriculoperito-

neal (VP) shunting were first performed at the end of the
19th century,1 but it was not until the development of sili-
cone rubber tubing and slit-valve tips in the 1960s that it
became a reliable and feasible procedure for the treatment of
hydrocephalus.2,3 After placement, however, complications
are frequent, especially in children.4 Shunt malfunction may
occur intracranially, along the shunt tract, or within the ab-
domen. Complications related to the peritoneal portion of
the shunt have been reported in as many as 25% of pa-
tients,2,3 although in current practice is generally less than
5%. Distal failure of the shunt system can be roughly divided
into biological complications and mechanical complica-
tions.5-7 Further, the presence of these shunts and the prob-
lems inherent with them can produce complications involv-
ing abdominal structures. This article will discuss these
abdominal complications of VP shunts and emphasize their
imaging findings.
that in some patients with acute shunt dysfunction that the
ventricles may not become enlarged.8,9 A plain radiographic
shunt series is also usually performed to assess the continuity
of the VP shunt tubing from the cranium to the distal end.10,11
Shunt fractures generally occur near the cranial connector or
within the neck, but can occur anywhere along the shunt
path. It is important to compare with old studies to assess if
the shunt tip is mobile; persistence of the shunt tip in one
location may indicate shunt entrapment that can impair CSF
drainage. Similarly, a soft-tissue density mass around a shunt
can indicate the formation of a CSF pseudocyst.
While a shunt series can assess shunt continuity, it cannot
assess shunt patency. A contrast study of the shunt is performed

Imaging of
VP Shunt Malfunction
Since the clinical presentation of patients with VP shunt dys-
function is variable, imaging is often required. Computed
tomography (CT) of the head is performed to evaluate for any
change in ventricular size. It must be remembered, however,

*Department of Radiology, Columbus Children’s Hospital, 700 Children’s

Drive, Columbus, Ohio.
†Section of Neurosurgery, Department of Surgery, Columbus Children’s
Hospital, 700 Children’s Drive, Columbus, Ohio.
Address reprint requests to: Brian D. Coley, MD, Department of Radiology,
Columbus Children’s Hospital, 700 Children’s Drive, Columbus, Ohio
43205, USA. E-mail: bcoley@chi.osu.edu
Figure 1 VP shunt infection and peritonitis. Contrast-enhanced CT
scan shows a focal fluid collection (*) with an enhancing wall next to
the VP shunt tip (arrow). Adjacent small bowel loops show thick-
ened walls (arrowheads).

152 0887-2171/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1053/j.sult.2006.01.009
Complications of ventriculoperitoneal shunts in children
Figure 2 VP shunt infection and focal abscess. Contrast-enhanced
CT scan shows an interloop abscess (*) with a thickened wall. The
tip of the shunt was located inferiorly.
by the instillation of nonionic myelographic contrast medium
into the shunt reservoir and then performing serial radiographs
following the flow of contrast. A properly functioning nonob-
structed shunt should allow prompt passage of contrast down
the shunt tubing into the peritoneal cavity. Shunt contrast stud-
ies can also be used to confirm shunt tip location in cases of
suspected catheter migration.12
CT and ultrasound (US) are used to evaluate for CSF pseudo-
cysts, shunt tip position in cases of migration, and abdominal
complications such as abscess and obstruction. US can usually
provide sufficient information when searching for pseudo-
cysts,13-15 but is more limited in evaluating the shunt itself. CT,
with radiation doses properly adapted for the pediatric patient,
Figure 3 CSF pseudocyst. A. Abdominal radiograph shows a soft-tissue density mass surrounding the VP shunt tip in
the left lower abdomen. B. Longitudinal sonogram shows an anechoic fluid collection associated with the shunt
(arrow).
153
provides an excellent global evaluation of the abdominal cavity
and shunt relationships.
Biological Shunt Complications
Shunt Infection, Peritonitis, and Abscess
Infection is a common complication of VP shunt proce-
dures1,4,7 and may predispose to most of the other complica-
tions to be discussed. Infection may occur at the time of shunt
placement, but more typically is acquired later. Any number
of organisms can be responsible, but Staphylococcus species
are the most common.7,16-18 The diagnosis is made by posi-
tive CSF cultures taken from the shunt reservoir, although it
must be remembered that there have been documented cases
of negative CSF cultures with cultures of removed shunt
hardware subsequently being positive.14,19,20
Most shunt infections produce shunt dysfunction, but do
not produce abdominal complications. However, occasion-
ally a primary shunt infection will spread to the peritoneum
and produce abdominal symptoms from peritonitis or focal
abscess formation.1,3,16,21 The patient with suspected perito-
nitis or abscess is best imaged with CT. Findings are the same
as with other causes of infection: fluid collections with en-
hancing margins, and inflammatory changes in adjacent mes-
enteric fat and bowel loops (Fig. 1). While the inflammatory
changes are generally associated with the presence of the VP
shunt catheter, infected collections may occur physically sep-
arate from the catheter (Fig. 2). Appendicitis has been re-
ported in association with VP shunts.16,22 However, appen-
dicitis is so common in children that any causative
relationship is unlikely.
154 B.D. Coley and E.J. Kosnik

Figure 4 CSF pseudocyst. (A) Contrast-enhanced CT scan shows a large fluid collection within the pelvis associated
with the VP shunt tip (arrow). (B) Plain radiograph performed after the CT scan shows displacement of bowel loops
away from the VP shunt tip. Also seen is delayed contrast emptying from the right renal collecting system with a dilated
right ureter (arrow) and delayed contrast excretion into a dilated left renal pelvis (arrowheads) from ureteral obstruc-
tion by the pseudocyst.

CSF Pseudocysts present with neurologic symptoms. Factors predisposing to CSF

Shunt loculation within the abdomen preventing the peritoneal pseudocyst formation include prior abdominal surgeries pro-
resorption of CSF occurs in 0.7 to 10% of patients.2,3,23-26 Chil- ducing peritoneal adhesions, and sterile inflammatory reactions
dren with CSF pseudocysts commonly present with abdominal to VP shunt materials and CSF proteins.15,20,24,26-28 Most impor-
complaints,14,15,23,24 in contrast to adults who more typically tant, however, is VP shunt infection and its sequelae,13-15,20,24-26,28

Figure 5 Perihepatic CSF pseudocyst. (A) Plain radiograph shows the VP shunt directed toward the lateral aspect of the liver.
(B) Contrast-enhanced CT scan shows an ovoid fluid collection lateral to the liver associated with the shunt (arrow).
Complications of ventriculoperitoneal shunts in children 155

Figure 6 Walled-off VP shunt. (A) Plain radiograph of a patient with VP shunt dysfunction shows a tightly coiled shunt
within the left upper quadrant (arrow). (B) Contrast shunt study shows contrast filling the catheter (arrowheads) and
a patent distal end with contrast collecting in a small loculated cavity (arrow). There is no free spill into the peritoneum.

Figure 7 Occluded VP shunt. Contrast shunt study shows contrast

within the abdominal portion of the catheter (arrowheads), but not Figure 8 Disconnected VP shunt. Plain radiograph in a child with
within the most distal portion (arrow). Even after pumping of the shunt dysfunction from a proximal disconnection with the ventric-
shunt reservoir, there was no peritoneal spill of contrast indicating ulostomy catheter shows the entire extracranial length of tubing has
distal obstruction. coiled within the peritoneum.
156
Figure 9 Distal VP shunt kink. Plain radiograph shows a sharp kink
in the distal shunt (arrow) with the tip (arrowhead) folded back 180
degrees.
although few patients actually exhibit symptoms related directly to
the infection itself.
On plain radiographs, CSF pseudocysts may appear as a
soft-tissue mass associated with the VP shunt catheter dis-
placing adjacent bowel loops or other structures. US or CT
readily shows these collections and confirms the association
with the shunt tip and can demonstrate any other complica-
tions13-15,29,30 (Figs. 3 and 4). If uncomplicated, the cyst con-
Figure 10 Short distal VP shunt. Plain radiograph shows the distal
shunt tip (arrow) ending just at the epigastrium. There was no shunt
tubing within the peritoneum.
B.D. Coley and E.J. Kosnik
Figure 11 VP shunt with colonic perforation. Plain radiograph of a
child with a shunt infection shows the distal shunt overlying the
rectum and extending below the bottom of the film (arrow). On
physical exam the shunt was visible extending from the anus.
tents are completely anechoic and without septations at US,
and the cysts have thin nonenhancing walls at CT. Complex
collections or those with thick and enhancing walls should
raise concern for superimposed infection.
While most CSF pseudocysts occur centrally within the peri-
toneal cavity, occasionally shunt tips may become trapped ad-
jacent to the liver and form localized collections (Fig. 5). These
may appear to be subcapsular collections or hepatic masses, and
if infected, may form a liver abscess.31,32
Shunt Obstruction
Obstruction is the most common cause of VP shunt malfunc-
tion requiring surgical shunt revision and may occur at either
the proximal or the distal end.2,4,7,17,18 Within the abdomen,
functional shunt occlusion can occur with CSF pseudocyst
formation, or if the catheter becomes walled-off in a small
cavity (likely the result of infection or inflammation), which
prevents the free egress of CSF into the peritoneum (Fig. 6).
The omentum may wrap itself around the distal shunt cath-
eter, usually as a response to infection, effectively blocking
CSF flow. Inflammatory response to the tubing itself can lead
to a buildup of cells and tissues within the catheter, produc-
ing obstruction.27
Routine imaging may show no abnormalities in many
cases, and contrast studies become necessary for evaluation.
An occluded distal shunt will prevent the free passage of CSF
(and contrast) into the peritoneal cavity, confirming the di-
agnosis (Fig. 7).
Complications of ventriculoperitoneal shunts in children 157

Figure 12 VP shunt with small bowel perforation. (A) CT scan shows shunt tubing apparently within right upper
quadrant small bowel (arrow). (B) Contrast shunt study shows contrast filling small bowel, confirming the shunt’s
intraluminal location.

Mechanical ture within the neck due to catheter fatigue. However, the cath-
eter can separate from any connector, or fracture anywhere
Shunt Complications along its course, making it essential to image the entire length of
Shunt Discontinuity and Kinking the shunt. Discontinuous portions of the catheter frequently
VP shunts most often become disconnected at the junction with migrate, and these fractured segments may come to lie com-
the one-way valve system, the ventriculostomy reservoir, or frac- pletely within the peritoneal cavity (Fig. 8).
Rarely, a catheter may develop a persistent sharp angulation
that prevents adequate CSF drainage17 (Fig. 9). A freely mobile
catheter will change position on serial radiographs; one that
does not may be abnormally fixed and tethered, which may
affect its performance.

Figure 14 VP shunt migration into the scrotum. Longitudinal sono-

Figure 13 VP shunt migration into the scrotum. Plain radiograph gram performed for scrotal swelling shows a VP shunt (arrowhead)
shows the distal shunt extending along the inguinal canal with the lying immediately superior to the testis (T) with a small surrounding
tip residing in the right scrotum. fluid collection (*).
158 B.D. Coley and E.J. Kosnik

Figure 17 VP shunt and hydrocele. Longitudinal sonogram of the

Figure 15 VP shunt migration into thorax. Chest radiograph in a
child with shunt dysfunction and respiratory symptoms shows in-
creased opacity of the left chest, a left pleural effusion (arrowhead),
and left lower lobe parenchymal consolidation. CSF was aspirated
from the left chest.
Inadequate Shunt Length
Children grow. If fortunate enough to not otherwise need a
shunt revision, a child will occasionally outgrow their shunt
length.11 Radiographs will show a shunt without any apparent
intraabdominal component (Fig. 10), something readily con-
firmed by CT.
Shunt Migration
As with any other foreign object placed within the body, VP
shunts do not always stay confined to the peritoneal cavity.
right scrotum from a patient with scrotal swelling shows fluid (*)
extending down from the inguinal canal above the testis (T) and
epididymis (E).
Catheters may migrate through preexisting pathways such as
a patent processus vaginalis1,33 or Bochdalek hernia34 or may
perforate normally intact hollow viscera. Perforations of the
intestine, gallbladder, umbilicus, bladder, vagina, and dia-
phragm and bronchial tree have all been reported.1-3,16,35-40
Presenting symptoms may relate to abnormal fluid accumu-
lation (scrotum and thorax), abnormal leakage of CSF (um-
bilicus and vagina), or unusual shunt infections with Gram-
negative organisms (bowel perforation).
Plain radiographs in patients with VP shunt bowel per-
foration may show unusual angulation or abnormal course
of the distal catheter (Fig. 11), but are frequently normal.
CT scans may suggest an intraluminal location, but col-
lapsed bowel or respiratory motion can sometimes make

Figure 16 VP shunt and small bowel obstruction. (A) Plain radiograph shows dilated proximal small bowel loops in the
left upper quadrant with normal-appearing distal bowel loops. (B) Contrast-enhanced CT scan shows dilated proximal
small bowel with an abrupt transition point (arrow) to normal caliber bowel. An adhesive band was found at surgery.
Complications of ventriculoperitoneal shunts in children
Figure 18 VP shunt and metastatic medulloblastoma. Contrast-en-
hanced CT scan in a child with medulloblastoma shows a large mass
(arrowheads) filling the cul-de-sac posterior to the VP shunt (ar-
row). Biopsy confirmed metastatic disease. (Case courtesy of Sheila
C. Berlin, MD, Cleveland, OH.)
this less clear. Contrast shunt studies will show intralumi-
nal accumulation of contrast, definitively proving shunt
migration (Fig. 12).
VP shunt migration into the scrotum is obvious on plain
radiographs as it traverses the inguinal canal into the scro-
tal sac (Fig. 13). Occasionally shunt migration will be
discovered during US performed for scrotal swelling. US
will reveal a “hydrocele” associated with the displaced VP
shunt (Fig. 14).
Thoracic migration is uncommon and may result from
inflammation and/or infection from the shunt or lung.37
While ventriculopleural shunts are sometimes performed for
patients in whom the peritoneum is no longer an option, it is
felt that the pleural space provides insufficient resorptive
surface in children less than 5 years of age.34,37,41 Migration
most commonly occurs on the right.34 Imaging discloses
pleural effusion and varying degrees of accompanying paren-
chymal consolidation or atelectasis (Fig. 15).
Abdominal
Visceral Complications
The presence of a VP shunt, the operations required for
placement, and the contents of ventricular drainage can
themselves cause abdominal complications. Adhesions pro-
duced by laparotomy, by infection, or from the presence of
the shunt catheter can lead to bowel obstruction.12 Imaging
reveals the typical findings of disproportionate small bowel
distension with normal distal bowel loops (Fig. 16). Intesti-
nal obstruction from volvulus around a shunt catheter,42 and
from shunt catheters encircling bowel,11 has also been re-
ported.
159
Children with VP shunts have a higher incidence of ingui-
nal hernias and hydroceles than children who have under-
gone ventriculoatrial shunting.1,3,17 The physical presence of
intraperitoneal CSF likely serves to keep the processus vagi-
nalis open and thus allows more hernias and hydroceles to
become clinically apparent.3 US is most useful for evaluating
the inguinal and scrotal region (Fig. 17).
Central nervous system tumors are the most common solid
neoplasms to occur in children, and many of these children
will require CSF shunting as part of their care. Tumors that
tend to spread through the CSF can thus potentially spread to
the peritoneal cavity via VP shunts.43,44 Abdominal com-
plaints relate to the presence of the mass and resultant com-
plications. US and CT readily show the tumor, with biopsy
confirming metastatic spread via the shunt (Fig. 18).
Conclusion
The extracranial shunting of hydrocephalic children that
seems so commonplace today has only had a reasonable
chance for success during the lifetime of most of the people
reading this. Complications occur with any implanted de-
vice, and VP shunt complications occur more commonly in
children than in adults. Abdominal complications are com-
mon and often difficult to diagnose in these medically com-
plex children. Appreciation of the imaging evaluation and
radiographic findings of the abdominal complications will
hopefully expedite proper neurosurgical care.
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