**3. Patients with VPS-related bowel complications**

Within this group, we consider patients with appendicitis, intestinal perforation, intestinal adhesions, intestinal volvulus, fistulas, plastron, anal extrusion of the peritoneal catheter, bladder perforation, abdominal wall perforation, and migration of the distal end of the catheter to the scrotal sac.

In this group of patients, it is also important to evaluate the functioning of the ventriculoperitoneal shunt valve with brain tomography and system radiographs. Because infections, intestinal rupture, among others. Can generate a malfunction of the shunt.

In patients with intestinal complications, the characteristics of the intestinal process and whether it is in contact with the distal catheter in the peritoneum should be assessed initially with abdominal ultrasound [27–32]. The multidisciplinary evaluation of the patient is mandatory by a medical clinic, infectology, and general surgeons, because many of these pathologies are surgically resolved by the general surgery service. In case of an infectious process such as appendicitis, in contact with the catheter distal to the valve or perforation, exteriorization of the shunt at the thoracic level is recommended. The distal catheter is considered contaminated and must, therefore, be removed from the abdominal cavity [33]. A CSF sample for culture should be taken from all patients and culture results should be awaited before placing a new shunt.

In patients in whom the CSF culture is positive, it is most likely an ascending infection caused by germs of abdominal origin. As it is an infection in the nervous system, the entire shunt system must be removed and an EVD placed until the infectious process is resolved [7]. After completing the appropriate antibiotic treatment for the infection, a new catheter should be placed. Preferably in the atrium of the heart to avoid a new approach to the abdomen, abdominal surgeries and infectious processes predispose to the formation of intestinal adhesions and/or a peritoneum with less

#### **Figure 2.**

*Abdominal ultrasonography shows the distal catheter and abundant peritoneal fluid (ascites). DC distal catheter, AC ascites.*

absorptive capacity. If the ventricular anatomy is favorable and the VTE success score is high, endoscopic surgery can be performed for treatment of hydrocephalus.

#### **4. VPS-related ascites**

Ascites are the abnormal accumulation of intraperitoneal fluid. Fluid accumulation occurs as a consequence of a nonabsorptive peritoneum. In addition to the clinical suspicion on physical examination, a globose abdomen, with an ascitic wave on palpation. Abdominal ultrasound is an imaging diagnostic method that, although it is operator dependent, is useful in diagnosing ascites (**Figure 2**). It is important to study the possible malfunction of the valve, so a brain tomography and x-rays of the system should also be requested [34–36].

In the case of the presence of ascites, CSF sampling is also recommended to rule out infection associated with the system. If the culture result is positive, removal of the shunt and placement of an EVD is recommended along with administration of antibiotics until resolution [37, 38].

If the patient has symptoms of intracranial hypertension, ventricular enlargement on CT scan, or dyspnea (respiratory distress) secondary to ascites, the shunt should be exteriorized while awaiting culture results. If cultures are negative, the site of choice for a new distal catheter is the atrium of the heart as reinsertion into the peritoneal cavity is not recommended [6, 35, 36] Although spontaneous resolution of ascites without the need for shunt intervention has been published, we recommend reinsertion of the catheter in a space other than the peritoneum [37]. If the patient is a candidate for endoscopic treatment of hydrocephalus, ETV could be considered.

Each patient must be managed individually based on their clinical context and the abdominal pathology associated with the shunt. The decision to remove the ventriculoperitoneal valve should be taken into account that CSF cell count, glucose, and protein may not be reliable indicators of infection and therefore do not justify immediate removal of the shunt [25].

#### **5. Conclusion**

DPVs have been used for the treatment of hydrocephalus for more than 60 years. Abdominal conditions in patients with shunts can make therapeutic decision-making *Abdominal Complications in Patients with a Ventriculoperitoneal Shunt DOI: http://dx.doi.org/10.5772/intechopen.110614*

difficult. The analysis of each case taking into account the presence of symptoms of intracranial hypertension and/or infection is important since in many cases a multidisciplinary team is required for treatment.
