Gastrointestinal Imaging • Original Research

Chung et al.
CT of Ventriculoperitoneal Shunts

Gastrointestinal Imaging
Original Research

Intraabdominal Complications
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Secondary to Ventriculoperitoneal
Shunts: CT Findings and Review of
the Literature
Jae-Joon Chung1 OBJECTIVE. The purpose of our study was to evaluate the abdominopelvic CT findings
Jeong-Sik Yu1 of various intraabdominal complications secondary to ventriculoperitoneal shunts for hydro-
Joo Hee Kim1 cephalus and to review the literature.
Se Jin Nam1 MATERIALS AND METHODS. The CT images of 70 patients (33 men and 37 women;
Myeong-Jin Kim 2 mean age, 48.5 years) who underwent ventriculoperitoneal shunt placement and abdominopel-
vic CT because of shunt-related abdominal symptoms were reviewed retrospectively. CT im-
Chung JJ, Yu JS, Kim JH, Nam SJ, Kim MJ ages 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 ventriculo-
peritoneal shunting operations undergone was 1.4 (range, 1–6). A total of 76 ventriculoperi-
toneal 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 patho-
logically 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 ab-
scess, three cases (4.3%) of infected fluid collection, and one case (1.4%) of bowel perfora-
tion. 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 sec-
ondary to ventriculoperitoneal shunt were shown, of which, shunt infection was the most
common, followed by CSF pseudocyst, abscess, and infected fluid collection.
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 shunt revision [1, 2]. The most common com-
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.
AJR 2009; 193:1311–1317
0361–803X/09/1935–1311
© American Roentgen Ray Society
P
lacement of a ventriculoperito-
neal shunt is the most common
operation performed in the treat-
ment of hydrocephalus. Intraab-
dominal complications after ventriculoperi-
toneal shunt placement are most commonly
located near the peritoneal end of the shunt
catheter; more than 50% of patients require
plications 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 her-
nia, subcutaneous collection of CSF, and
peritoneal pseudocyst formation due to low-
grade infection followed by wrapping by the
omentum [2–4]. Other complications report-
ed in the literature include intestinal perfora-
tion, CSF ascites, inguinal hernia, and intes-
tinal volvulus [5–7]. These complications
may manifest as either local abdominal signs
or increased intracranial pressure.
Shunt infection remains a frequent and po-
tentially fatal complication of CSF diversion.
Therefore, a key issue in the treatment of
these complications is early and correct di-
agnosis of intraabdominal complications by
CT, MRI, sonography, or abdominal radiog-
raphy. 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 ventriculoperito-
neal 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

 Chung et al.

informed consent was waived. We reviewed the
medical records of all patients who underwent ab-
dominopelvic CT after ventriculoperitoneal shunt
placement from January 2001 to June 2008. The
medical records of 100 consecutive patients were
reviewed. An attending abdominal radiologist re-
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of 70 patients (33 male and 37 female; age range,
2–75 years; mean age, 48.5 years) were enrolled
in this study.
The causes of hydrocephalus in the 70 patients
were 14 cases of primary or secondary brain tu-
mors, 12 cases of subarachnoid hemorrhage and in-
gutter (RPG), left paracolic gutter (LPG), midab-
domen (paraumbilical area), pelvic cavity (below
acetabular roof), and abdominal wall.
One abdominal radiologist with 14 years of ex-
perience reviewed all the abdominopelvic CT im-
ages, focusing on the site and size of localized flu-

trieved the images from a hospital archiving sys-
tem and conducted a preliminary review of the CT
images of the 100 patients.
Among the patients reviewed, a total of 30 were
excluded for the following reasons: seven patients
had no specific abdominal symptoms (staging
workup for underlying cancer [n = 4], evaluation
of hypertension [n = 2], and falling injury [n =
1]); five patients had no recorded clinical infor-
mation for an abdominopelvic CT scan; five pa-
tients underwent ventriculoperitoneal shunt re-
moval just before the CT for shunt malfunction;
four patients underwent CT for evaluation of per-
cutaneous endoscopic gastrostomy tube place-
ment; three patients underwent CT for renal or
ureteral stones; three patients underwent CT for
urinary tract infection; two patients underwent CT
for gallstones; and one patient underwent CT for
voiding difficulty. Inclusion criteria for the study
included abdominopelvic CT with previous ven-
triculoperitoneal shunt placement and abdominal
symptoms such as diffuse or localized abdominal
pain, fever with abdominal symptoms, advanced
hydrocephalus because of shunt malfunction, ven-
triculitis because of shunt infection, prolonged di-
arrhea, abdominal wall mass, pus discharge from
the operation site, and hematochezia. After ex-
clusion of the aforementioned 30 patients, a total
traventricular hemorrhage (IVH), 11 cases of trau-
matic intracerebral hemorrhage (ICH) and IVH, six
cases of postoperative ischemic change, six cases of
postoperative hemorrhage, five cases of hyperten-
sive ICH and IVH, four cases of IVH, three cases of
tumor seeding, two cases of vascular ICH and IVH,
two cases of ICH after infarct, two cases of congen-
ital disease, two cases of meningitis, and one case
of subdural hematoma. Two cases of vascular ICH
and IVH were from a case of moyamoya disease
and a case of arteriovenous malformation (AVM).
Two cases of congenital diseases were from a case
of congenital hydrocephalus and a case of Arnold-
Chiari malformation.
The window for abdominopelvic CT was from
2 cm above the right hemidiaphragm to 2 cm be-
low the symphysis pubis, with a 7-mm collima-
tion and a 7-mm reconstruction interval. After IV
administration of 120–150 mL of nonionic iodi-
nated contrast medium (iopromide, Ultravist 300,
Schering), given by an automatic injector at 3–4
mL/s, 3-minute delayed equilibrium phase images
were obtained. All scanned images were sent to
the PACS for interpretation.
The locations of intraperitoneal fluid collections
were divided into right upper quadrant (RUQ),
right lower quadrant (RLQ), left upper quadrant
(LUQ), left lower quadrant (LLQ), right paracolic
id collection, the presence of walls or septa in the
localized fluid collections, peritoneal thickening,
peritoneal contrast enhancement, omentomesen-
tery infiltration, abscess, bowel perforation, bow-
el-wall thickening and contrast enhancement,
abdominal wall infiltration, thickening of the
catheter track wall, and intraperitoneal free air.
Results
Abdominopelvic CT was performed in 70
patients for complaints of varying abdominal
symptoms, such as diffuse abdominal pain
(n = 25), localized abdominal pain (n = 17),
aggravated hydrocephalus due to shunt mal-
function (n = 9), fever with vague abdominal
symptoms (n = 6), ventriculitis with suspect-
ed shunt infection (n = 5), prolonged diar-
rhea (n = 3), palpable abdominal mass (n =
2), subphrenic free air (n = 1), pus discharge
from the operation site (n = 1), and hemato-
chezia (n = 1).
Twelve (70.6%) of the 17 patients with lo-
calized abdominal pain complained of lower
abdominal pain. Among the 12 patients with
lower abdominal pain, six had RLQ pain that
was initially diagnosed as acute appendici-
tis, two (2.9% of all patients) of whom were
finally diagnosed with acute appendicitis.

A B
Fig. 1—51-year-old woman with large pseudocyst in abdominal wall.
A, Contrast-enhanced abdominopelvic CT scan shows about 13 × 10 cm pseudocyst in subcutaneous layer of right anterior abdominal wall with internal
ventriculoperitoneal shunt catheter. Smoothly compressed abdominal wall muscle is noted. Causes of hydrocephalus were subarachnoid hemorrhage and
intraventricular hemorrhage.
B, More caudal CT image shows pericystic irregular fluid collections (arrows) in abdominal wall. This patient complained of aggravated headache because of advanced
hydrocephalus from shunt malfunction. Subsequently, shunt revision was performed, and there was no growth of microorganism from catheter tip.

1312 AJR:193, November 2009

 CT of Ventriculoperitoneal Shunts

Ventriculitis was suspected in five patients Fig. 2—33-year-old man with

because of findings on brain CT or MRI ex-
aminations that were performed for acute
and persistent headache or increased intra­
cranial pressure.
The mean period between the last ventric-
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localized omentomesentery
infiltration. Contrast-enhanced
abdominopelvic CT scan shows
localized dirty infiltration in
omento­mesentery of abdominal
left lower quadrant (LLQ) with
adjacent peritoneal thickening

uloperitoneal shunting operation and abdom- and minimal fluid collection.

inopelvic CT was 11 months (range, 1 week
to 115 months), and the mean number of ven-
triculoperitoneal shunting operations under-
gone was 1.4 (range, 1–6).
In the 70 patients, 76 ventriculoperitoneal
shunting catheters were introduced: 64 pa-
tients with a unilateral catheter and six pa-
tients with bilateral catheters. There were 46
right ventricle–origin shunting catheters and
30 left ventricle–origin shunting catheters;
six patients had bilateral ventriculoperitone-
al shunting catheters placed.
In the 70 patients, 87 localized fluid col-
lection sites, of which 47 patients (67.1%)
had one fluid collecting site, 17 (24.3%) had
two fluid collecting sites, and two (2.9%) had
three fluid collecting sites, as well as six CSF
pseudocysts were found. The locations of the
87 localized fluid collection sites were the
pelvic cavity (n = 55), RPG (n = 16), mid­
abdomen (n = 5), LPG (n = 4), RLQ (n = 3),
abdominal wall (n = 1), RUQ (n = 1), LUQ
(n = 1), and LLQ (n = 1). Among them, one
patient had fluid collections in both paracolic
gutters. The locations of the six CSF pseudo-
cysts were the RLQ (n = 3), pelvis (n = 2),
and abdominal wall (n = 1) (Fig. 1).
Ventriculoperitoneal shunt
catheter (arrows) is noted within
localized infection area. Cause of
hydrocephalus was postoperative
intraventricular hemorrhage for
arteriovenous malformation and
patient complained of localized
abdominal pain in abdominal LLQ.
Shunt revision was performed and
Staphylococcus aureus grew from
tip of shunt catheter.
Of the 70 patients, 16 (22.9%) were histo-
pathologically diagnosed with shunt-relat-
ed complications, which included 11 cases
(15.7%) of shunt infection (Fig. 2), six cases
(8.6%) of CSF pseudocyst formation (Fig. 3),
four cases (5.7%) of abdominal abscess (Fig.
4), three cases (4.3%) of infected localized flu-
id collection (Fig. 5), and one case (1.4%) of
bowel perforation. Among these, all four cases
of abscess, three cases of pseudocyst, and two
cases of infected localized fluid collection co-
existed in the patients with shunt infection.
Of the six cases (8.6%) of CSF pseudo-
cysts, five were located in the peritoneal
space and one was located in the abdomi-
nal wall. One case (Fig. 6) of pseudocyst
caused small-bowel obstruction secondary
to wrapped mesentery at the catheter tip
within 5 days of ventriculoperitoneal shunt
placement. Three cases of infected fluid col-
lection were diagnosed by sonographically
guided aspiration of fluid. One patient with
subphrenic free air was diagnosed with peri-
tonitis secondary to a 5-mm bowel perfora-
tion in the transverse colon due to the shunt-
ing catheter.
Eighteen patients (25.7%) showed a wall of
fluid collection, 12 (17.1%) of which showed
contrast enhancement of the wall. Seven cas-
es (10.0%) showed internal septa within the
fluid collection. There were 30 cases (42.9%)
of peritoneal thickening, 19 cases (27.1%) of
peritoneal enhancement, 34 cases (48.6%) of
omentomesentery infiltration (Figs. 2 and 5),

A B
Fig. 3—20-year-old man with intraperitoneal pseudocyst and inflammatory infiltration in abdominal wall.
A, Contrast-enhanced abdominopelvic CT scan shows 11 × 6 cm pseudocyst in abdominal right lower quadrant with enhanced wall and internal shunt catheters (arrows).
Small amount of fluid collection is also seen in both paracolic gutters. Causes of hydrocephalus were traumatic hemorrhage and postoperative ischemic change. CT was
performed because of abdominal pain.
B, More cephalic CT image shows inflammatory fatty infiltration in subcutaneous layer of right midabdominal wall with adjacent skin thickening. Adjacent small-bowel
loops show mild wall thickening with mesenteric haziness and fluid collections in both paracolic gutters. There was no growth of microorganisms from catheter tip and
shunt externalization was performed.

AJR:193, November 2009 1313

 Chung et al.

Fig. 4—14-year-old boy with lumboperitoneal shunt, and a third ventricu-

intraperitoneal abscess. Contrast-
enhanced 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.
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lostomy [13]. The peritoneal cavity is prefer-
able to the pleural cavity for insertion or re-
insertion of the shunt [6].
The most common causes of shunt mal-
function are catheter obstruction and infection.

Cause of hydrocephalus was The incidence of ventriculoperitoneal shunt–

four cases (5.7%) of abscess, one case (1.4%)
of bowel perforation, nine cases (12.9%) of
bowel-wall thickening, 38 cases (54.3%) of
abdominal wall infiltration (Fig. 3), and sev-
en cases (10.0%) of thickening of the cathe-
ter track wall in the abdominal wall.
Specimen cultures from the peritoneal tips
of the shunt catheter or intraperitoneal fluid
were obtained in 21 patients (30.0%). The fol-
lowing microorganisms grew in 11 patients
(15.7%): five cases of Staphylococcus aureus,
one case of Pseudomonas aeruginosa, one
case of vancomycin-resistant enterococci, one
case of Acinetobacter baumannii, one case of
Micrococcus species, one case of gram-posi-
tive cocci, and one case of gram-negative coc-
ci. In 10 patients, there was no growth.
congenital Arnold-Chiari
malformation. CT was performed
because of suspicion of shunt
malfunction. Two shunt catheters
are noted in both sides of
abdominal wall with distal catheter
near descending colon. This lesion
was confirmed as abscess by
percutaneous needle aspiration,
and Pseudomonas aeruginosa
grew from aspirated abscess fluid.
Shunt catheter was removed.
For the treatment of ventriculoperitoneal
shunt–related abdominal complications in the
16 patients (22.9%), the following were used:
antibiotic therapy only (n = 4), shunt exter-
nalization and antibiotic therapy (n = 2), ex-
ploratory laparotomy (n = 2), shunt revision
(n = 2), sonographically guided percutaneous
drain tube insertion (n = 2), removal of the
catheter (n = 2), laparotomy and drainage (n =
1), and conservative treatment (n = 1).
Discussion
The use of the peritoneal cavity for CSF
absorption in ventriculoperitoneal shunting
was first introduced in 1908 by Kausch [12].
Other shunting techniques have since been
used and include a ventriculoatrial shunt, a
related abdominal complications has been re-
ported to be from 5% to 47% [14, 15]. In our
study, 16 patients (22.9%) were histopatholog-
ically diagnosed with shunt-related compli-
cations. The most common distal ventriculo-
peritoneal shunt complications include shunt
infection, subcutaneous collection of CSF,
peritoneal pseudocyst, bowel perforation, in-
testinal volvulus [6], mesenteric pseudotumor,
migration of the catheter into the pleural cav-
ity and heart, and development of an incision
hernia [8–11, 16–20]. Other less-common ab-
dominal complications [21, 22] include bowel
obstruction secondary to adhesion; subphren-
ic abscess, cerebrospinal–enteric fistula; un-
treatable CSF ascites; catheter disconnection;
and extraperitoneal retraction of the catheter
through the mouth [10], umbilicus [4], blad-
der, vagina, anus [11], or scrotum. Nonenter-
ic viscus perforations also can occur and can
involve multiple organs, such as the gallblad-
der, stomach, liver, uterus, or urethra. Obstruc-
tion of the distal catheter must be treated as an
emergency because it can lead to a significant
increase in intracranial pressure, resulting in
associated complications that can cause con-
siderable morbidity and possibly death [5].

A B
Fig. 5—67-year-old woman with intraperitoneal infected fluid collection.
A, Contrast-enhanced abdominopelvic CT scan shows large amount of ascites with thickened and enhanced peritoneum (arrows) with ventriculoperitoneal shunt
catheter in left lower abdomen. Causes of hydrocephalus were subarachnoid hemorrhage and intraventricular hemorrhage. CT was performed because of abdominal
pain, nausea, and vomiting.
B, More cephalic CT image shows loculated fluid collections with thin wall in both sides of midabdomen. Dirty fatty infiltration is also seen in omentomesentery of
right midabdomen, with fluid collections in right paracolic gutter and mesentery. Micrococcus species grew from tip of shunt catheter. External drainage tube was
inserted for treatment.

1314 AJR:193, November 2009

 CT of Ventriculoperitoneal Shunts
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A B
Fig. 6—48-year-old man with intraperitoneal pseudocyst causing small-bowel obstruction.
A, Contrast-enhanced abdominopelvic CT scan shows approximately 6 × 5 cm pseudocyst in abdominal right lower quadrant with adherent and distended neighboring
small-bowel loops. Shunt catheter (arrow) is seen just below peritoneum. Cause of hydrocephalus in this patient was chondrosarcoma in skull base, and CT was
performed because of abdominal pain.
B, More cephalic CT image shows considerably more distended small-bowel loops with internal bowel contents and air–fluid level, suggesting mechanical bowel
obstruction. Laparoscopy confirmed small-bowel obstruction caused by adherent pseudocyst secondary to wrapped mesentery at catheter tip. Ventriculoperitoneal
shunt catheter was removed and reintroduced into another site. No microorganism grew from pseudocyst fluid.

Malfunction of the ventriculoperitoneal
shunt after initial placement occurs in ap-
proximately 25–35% of patients at 1 year
[23], and 70–80% of patients require at least
one revision at some point in their lives [16].
Cochrane and Kestle [24] reported the initial
shunt failure rate to be 31% at 6 months for
experienced surgeons, with an infection rate
of 7% over the same period. In our study, the
mean period between the last ventriculoperi-
toneal shunting operation and abdominopel-
vic CT was 11 months; 52 patients (74.3%)
had an interval of less than 11 months.
Among these 52 patients, eight underwent
abdominopelvic CT within 1 week because
of abdominal symptoms. One of these eight
patients underwent laparotomy because of
small-bowel obstruction caused by small-
bowel mesentery wrapping around the cath-
eter tip and pseudocyst.
Shunt infection remains a frequent and po-
tentially fatal complication of CSF diversion,
with a reported incidence of 5–47% [14, 15],
and approximately 70% of shunt infections
occur within 2 months after shunt placement
[13, 25]. In our study, shunt infection was
confirmed by bacterial culture in 11 patients
(15.7%). The most common organism was S.
aureus. However, it has been reported that
7% of ventriculoperitoneal shunt infections
are caused by Escherichia coli [17].
Peritoneal fluid is either absent or pres-
ent in only a small amount in patients with
normally functioning ventriculoperitoneal
shunts. CSF loculation may present as re-
current ascites, a peritoneal cyst, an omental
cyst, or subphrenic or lesser sac loculation
[8]. Peritoneal CSF pseudocyst formation is
an unusual complication, with a reported in-
cidence of less than 1.0–4.5% [8, 26]. The
wall of the pseudocyst is composed of fi-
brous tissue or an inflamed serosal surface
without an epithelial lining and is filled with
CSF and debris [8, 27]. The most common
presentation of an abdominal CSF pseudo-
cyst in children is elevated intracranial pres-
sure and abdominal pain, whereas local ab-
dominal signs, such as abdominal pain,
distention, nausea, or vomiting, predominate
in adults [8].
An abdominal CSF pseudocyst was first
described by Harsh [28] in 1954. Hahn et
al. [29] reported that infection was the most
prominent cause of pseudocyst formation
(80%) and emphasized that all cases of ab-
dominal pseudocysts should be considered
to be caused by infection until proven other-
wise. The most common intraabdominal re-
sponse to infection is sheathing of the peri-
toneal catheter. The CSF draining into these
sheaths may produce large intraabdominal
fluid-filled cysts [8]. The infection and sub-
sequent high levels of CSF protein, allergic
reactions to immunization [30], liver dys-
function [19], and tissue reaction against tub-
ing material and CSF protein [20] have been
known to impair the absorption of CSF and
to have a role in pseudocyst formation.
The time from the last shunting procedure
to the development of an abdominal pseudo-
cyst ranges from 3 weeks to 5 years [16].
There has been a reported case of pseudocyst
formation 10 years after ventriculoperitone-
al shunt placement. In our study, six cases
(8.6%) of pseudocyst were detected, and the
time interval between the last shunting oper-
ation and abdominopelvic CT ranged from 5
days to 25 months. The CSF pseudocyst can
either move freely within the peritoneal cav-
ity or adhere to loops of small bowel, the se-
rosal surface of solid organs, or the parietal
peritoneum [8].
CSF pseudocysts can be differentiated
from ascites by their characteristic displace-
ment of the bowel gas pattern on abdominal
films and by the absence of shifting dullness
[8]. Although sonography and CT can accu-
rately localize abdominal fluid collections,
differentiation of ascites from the aforemen-
tioned cystic lesions may not be possible.
Therefore, fine-needle aspiration of the lo-
calized CSF collections under sonographic
or CT guidance should be performed to in-
crease the diagnostic yield. Coley et al. [31]
reported that although the sonographically
guided percutaneous aspiration of CSF
pseudocyst was not curative, performance of
this procedure to alleviate the acute symp-
toms followed by elective shunt revision is a
feasible alternative to the traditional treat-
ment approach and could be helpful to limit
radiation exposure to patients who were likely

AJR:193, November 2009 1315


to have significant exposure during their
lives, especially children.
If infection is present, the pseudocyst wall
should be excised and the peritoneal shunt-
ing catheter removed [8]. In our study, 18
cases (25.7%) showed a wall of fluid collec-
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tion, of which 12 cases (17.1%) showed wall
enhancement and seven (10.0%) showed in-
ternal septa; however, histopathologic diag-
noses via fluid aspiration were available in
only a few cases.
Once the shunt tip is removed, the pseudo-
cyst gradually collapses because there is no
secretory epithelium present in the cyst [3].
The formation of a CSF pseudocyst is a poor
prognostic sign for the usefulness of the peri-
toneal cavity for shunting [32]. Although
previous abdominal pseudocyst formation
and peritonitis are not contraindications to
subsequent peritoneal shunting in some re-
ports [19, 29], the CSF had to be diverted to
other cavities because of either recurrence of
the cysts or failure of the peritoneum to ab-
sorb fluid [27]. Culture of the tip of the peri-
toneal catheter was reported to be more sen-
sitive than culture of the CSF [8].
Bowel perforation is a rare complication of
ventriculoperitoneal shunt placement, occur-
ring in less than 0.1–0.7% of cases [9], among
which nearly half are diagnosed after removal
of the catheter. Possible causes of bowel per-
foration include the sharp tip of the shunting
catheter, subclinical shunt infection, and in-
creased protein content in the CSF [11]. Re-
cently, silicon allergy, which may result in a
foreign body–like reaction, has been impli-
cated in the breakdown and perforation of the
bowel wall [18]. This complication can lead
to fatal meningeal infection when not rec-
ognized early. The overall mortality rate of
bowel perforation is nearly 15% in shunted
patients [26]. In our study, one case (1.4%)
of bowel perforation initially presented with
subphrenic free air, and a subsequent abdomi-
nopelvic CT and exploratory laparotomy were
performed, showing transverse colon perfora-
tion by the catheter tip. 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].
Bowel perforation can occur immediate-
ly after shunt placement or months or years
later. Clinicians must be vigilant in their as-
sessment for the presence of the following
clinical conditions in shunted patients: men-
ingitis or ventriculitis caused by an enteric
microorganism (e.g., E. coli) and abdominal
1316 AJR:193, November 2009
Chung et al.
symptoms, such as prolonged unexplained
diarrhea and fever [10]. Bowel perforation
should be suspected in cases of shunt infec-
tion by gram-negative bacilli, pneumoceph-
alus, prolonged unexpected diarrhea with
sterile cultures, or abdominal pain [22].
The risk of ventriculoperitoneal shunt–
related complications varies with the use of
prophylactic antibiotics, size and condition
of the patient, and experience of the operat-
ing surgeon. Recognition of these facts and
consequent changes in treatment have result-
ed in a steady improvement in the outcomes
of patients undergoing ventriculoperitoneal
shunt placement [33].
The imaging techniques for early detection
of intraabdominal complications secondary
to ventriculoperitoneal shunt include radiog-
raphy, sonography, CT, and MRI. On radiog-
raphy, the location of the shunt tip, displaced
bowel gases, soft-tissue mass of pseudocyst,
and intraperitoneal free air can be seen. On
sonography, the internal content, septa, and
wall thickness of pseudocysts can be observed
well. On contrast-enhanced CT or MRI, the
peritoneal thickening, bowel-wall thickening
and contrast enhancement, omentomesentery
infiltration, abscess, axial location of shunt tip
and adjacent abnormal findings, and localized
extraluminal air densities because of bow-
el perforation can be well evaluated. Among
these techniques, however, CT may be more
useful for the exact diagnosis of complicated
intraabdominal abnormalities.
There are a few limitations to this study. The
study is retrospective; therefore, 30 cases were
excluded for various reasons. The number of
pathologically confirmed cases was small,
with only 15.7% of microorganisms being cul-
tured. Infiltration or infection of the abdomi-
nal wall, catheter track, 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. The localized peritoneal
fluid collections with contrast-enhanced walls
or internal septa were not analyzed for possible
infection or localized peritonitis.
Nevertheless, we believe that familiarity
with the broad spectrum of ventriculoperi-
toneal shunt complications will enhance the
role of radiologists in the management of in-
traabdominal complications [7]. A high de-
gree of suspicion and careful clinical and ra-
diologic examinations could help diagnose
and treat ventriculoperitoneal shunt–related
complications before they progress to more
serious conditions.
References
1. Borgbjerg BM, Gjerris F, Albeck MJ, Hauerberg
J, Borgesen SE. Frequency and causes of shunt
revisions in different cerebrospinal fluid shunt
types. Acta Neurochir (Wien) 1995; 136:189–194
2. Sells CJ, Shurtleff DB, Loeser JD. Gram-negative
CSF shunt associated infections. Pediatrics 1977;
59:614–618
3. Acharya R, Ramachandran CS, Singh S. Laparo-
scopic management of abdominal complications
in ventriculoperitoneal shunt surgery. J Lap-
aroendosc Adv Surg Tech 2001; 11:167–170
4. Wani AA, Ramzan A, Wani MA. Protrusion of a
peritoneal catheter through the umbilicus: an un-
usual complication of a ventriculoperitoneal
shunt. Pediatr Surg Int 2002; 18:171–172
5. Nfonsam V, Chand B, Rosenblatt S, Turner R, Lu-
ciano M. Laparoscopic management of distal ven-
triculoperitoneal shunt complications. Surg En-
dosc 2008; 22:1866–1870
6. Bal RK, Singh P, Harjai MM. Intestinal volvulus:
a rare complication of ventriculoperitoneal shunt.
Pediatr Surg Int 1999; 15:577–578
7. Sathyanarayana S, Wylen EL, Baskaya MK, Nanda
A. Spontaneous bowel perforation after ventriculo-
peritoneal shunt surgery: case report and a review of
45 cases. Surg Neurol 2000; 54:388–396
8. Sharma AK, Pandey AK, Diyora BD, Mamidanna
R, Sayal PP, Ingale HA. Abdominal CSF pseudo-
cyst in a patient with ventriculo-peritoneal shunt.
Indian J Surg 2004; 66:360–363
9. Martinez Hernández-Magro P, Román CB, Sáenz
EV, Zavala MJ. Colonic perforation as a compli-
cation of ventriculoperitoneal shunt: a case report.
Tech Coloproctol 2006; 10:353–355
10. Berhouma M, Messerer M, Houisssa S, Khaldi M.
Transoral protrusion of a peritoneal catheter: a
rare complication of ventriculoperitoneal shunt.
Pediatr Neurosurg 2008; 44:169–171
11. Ghritlaharey RK, Budhwani KS, Shrivastava DK,
et al. Trans-anal protrusion of ventriculo-perito-
neal shunt catheter with silent bowel perforation:
report of ten cases in children. Pediatr Surg Int
2007; 23:575–580
12. Kausch W. Die Behandlung des Hydrocephalus der
kleinen Kinder. Arch Kiln Chir 1908; 87:709–796
13. Gupta DK, Dave S. Hydrocephalus. In: Gupta
DK, ed. Textbook of neonatal surgery. New Delhi,
India: Modern Publishers, 2000:434–450
14. Esposito C, Porreca A, Gangemi M, et al. The use of
laparoscopy in the diagnosis and treatment of ab-
dominal complications of ventriculoperitoneal shunts
in children. Pediatr Surg Int 1998; 13:352–354
15. Lortat-Jacob S, Pierre-Kahn A, Renier D, et al.
Abdominal complications of ventriculoperitoneal
shunts in children: 65 cases. Chir Pediatr 1984;
25:17–21
16. Blount JP, Campbell JA, Haines SJ. Complications
 CT of Ventriculoperitoneal Shunts

in ventricular cerebrospinal fluid shunting. Neu-
rosurg Clin N Am 1993; 4:633–656
17. Walters BC, Hoffman HJ, Hendrick EB, Hum-
phreys RP. Cerebrospinal shunt infection: influ-
ences on initial management and subsequent out-
come. J Neurosurg 1984; 60:1014–1021
Downloaded from www.ajronline.org by 202.80.219.177 on 02/14/23 from IP address 202.80.219.177. Copyright ARRS. For personal use only; all rights reserved
BE, Chandler WF. Unusual abdominal complica-
tions of ventriculo-peritoneal shunts. Radiology
1983; 146:323–326
23. Vinchon M, Fichten A, Delestret I, Dhellemmes
P. Shunt revision for asymptomatic failure: surgi-
cal and clinical results. Neurosurgery 2003; 52:
28. Harsh GR. Peritoneal shunt for hydrocephalus uti-
lizing the fimbria of the fallopian tube for entrance
to the peritoneal cavity. J Neurosurg 1954; 11:
284–294
29. Hahn YS, Engelhard H, McLone DG. Abdominal
CSF pseudocyst: clinical features and surgical

18. Brownlee JD, Brodley JS, Schaefer IK. Colonic
perforation by ventriculoperitoneal shunt tubing:
a case of suspected silicon allergy. Surg Neurol
1998; 49:21–24
19. Latchaw JP Jr, Hahn JF. Intraperitoneal pseudo-
cyst associated with peritoneal shunt. Neurosur-
gery 1981; 8:469–472
20. Rainov N, Schobess A, Heidecke V, Burkert W.
Abdominal CSF pseudocyst in patients with ven-
triculo-peritoneal shunts: report of fourteen cases
and review of literature. Acta Neurochir (Wien)
1994; 127:73–78
21. Paddon AJ, Horton D. Knotting of distal ventricu-
loperitoneal shunt tubing. Clin Radiol 2000;
55:1–3
22. Agha FP, Amendola MA, Shirazi KK, Amendola
347–353
24. Cochrane DD, Kestle JR. The influence of surgi-
cal operative experience on the duration of first
ventriculoperitoneal shunt function and infection.
Pediatr Neurosurg 2003; 38:295–301
25. Kumar R, Singh V, Kumar MV. Shunt revision in
hydrocephalus. Indian J Pediatr 2005; 72:843–847
26. Oh A, Wildbrett P, Golub R, Yu LM, Goodrich J,
Lee T. Laparoscopic repositioning of a ventriculo-
peritoneal catheter tip for a sterile abdominal ce-
rebrospinal fluid (CSF) pseudocyst. Surg Endosc
2001; 15:518
27. Parry SW, Schuhmacher JF, Llewellyn RC. Ab-
dominal pseudocysts and ascites formation after
ventriculoperitoneal shunt procedures: report of
four cases. J Neurosurg 1975; 43:476–480
management. Pediatr Neurosci 1985–1986; 12:
75–79
30. Dean DF, Keller IB. Cerebrospinal fluid ascites: a
comparison of a ventriculoperitoneal shunt. J
Neurol Neurosurg Psychiatry 1972; 35:474–476
31. Coley BD, Shiels WE II, Elton S, Murakami JW,
Hogan MJ. Sonographically guided aspiration of
cerebrospinal fluid pseudocysts in children and
adolescents. AJR 2004; 183:1507–1510
32. Fischer EG, Shillito J Jr. Large abdominal cysts: a
comparison of peritoneal shunts: report of three
cases. J Neurosurg 1969; 31:441–444
33. Pittman T, Williams D, Weber TR, Steinhardt G,
Tracy T Jr. The risk of abdominal operations in
children with ventriculoperitoneal shunts. J Pedi-
atr Surg 1992; 27:1051–1053

F O R YO U R I N F O R M AT I O N
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AJR:193, November 2009 1317