ABDOMINAL PAIN OF THE RIGHT UPPER QUADRANT

Abstract

A 77-year-old woman, with a ventriculoperitoneal shunt for normal pressure hydrocephalus since August 2007, was referred for evaluation of constant abdominal pain in the right upper quadrant for 4 weeks. Clinical abdominal examination revealed pain in the right upper quadrant by palpation and percussion. Laboratory evaluation revealed a leucocytosis of 12890 per microliter, a serum γ-glutamyltransferase of 283 U per liter, a serum alkaline phosphatase level of 377 U per liter, an alanine aminotransferase level of 120 U per liter, an aspartate aminotransferase level of 78 U per liter and a C-reactive protein of 212 mg per liter. Abdominal radiographs showed a ventriculoperitoneal shunt in the right upper quadrant (fi gure 1). An abdominal ultrasonographic study revealed an organized hyporefl ective collection in the left lobe of the liver with a diameter of 10 cm and thickness of 5 cm. Computed tomography of the abdomen showed a perihepatic collection of 8 Hounsfi eld Units, consistent with the density of water. The ventriculoperitoneal shunt is located into this subcapsular collection (fi gure 2). We diagnosed a spontaneous shift of the ventriculoperitoneal shunt into the liver causing a subcapsular collection of cerebrospinal fl uid. The patient was transferred to the neurosurgical unit for repositioning. Figure 1 : Abdominal radiographs showed a ventriculoperitoneal shunt in the right upper quadrant (panel A). Panel B shows a radiograph of 2 months earlier with a normal position of the ventriculoperitoneal shunt.