Case Author(s): David A. Hillier, M.D., Ph.D. and Jerold Wallis, M.D. , . Rating: #D3, #Q3

Diagnosis: Obstructed Denver shunt

Brief history:

66 year-old with history of cholangiocarcinoma.

Images:

Denver shuntogram

View main image(ps) in a separate image viewer

View second image(fl). Denver shunt contrast injection

View third image(ct). Computed tomography

Full history/Diagnosis is available below

Diagnosis: Obstructed Denver shunt

Full history:

66 year-old with history of cholangiocarcinoma and malignant ascites. He now presents with increasing abdominal distension.

Radiopharmaceutical:

Denver shuntogram, 5.5 mCi Tc-99m maa intraperitoneally

Findings:

1. Denver shuntogram (12/7/98) (films 1-4):

- Free flow of tracer throughout the peritoneal cavity

- No activity is seen in the blood or lungs. Transmission images (with sheet source behind patient) faintly show expected position of lungs on this image.

2. Computed tomography of chest and abdomen :

- Interval development of massive ascites between the two studies. Chest CT (not shown) also demonstrates numerous pulmonary nodules consistent with metastatic disease.

Discussion:

Peritoneal-venous shunting (Denver shunt) is used in cases of intractable ascites. A variety of shunts have been devised, including the Hyde shunt (1966-1974), LaVeen shunt (1974-1980) and Denver shunt (predates the LaVeen shunt, but is more popular today). They work approximately equally well (Hyde, et al.).

Intractable ascites is initially treated medically with bedrest, sodium restriction and combinations of diuretics (spironolactone, chlorothiazides, loop diuretics). If ascites is sufficiently severe to cause restricted mobility or respiration and if this is unsuccessful after several weeks, a shunt may be considered.

A variety of other methods have been attempted with limited success. These include repeated paracentesis (this may be complicated by hyponatremia, hypokalemia and hypoproteinemia), ascitic drainage through the bladder, peritoneal glass button (through which ascites may be drained), subcutaneous fistula, hepatoplexy, ileoentrectomoy, thoracic duct drainage and portocaval shunting (Hyde, et al).

Imaging was performed using intraperitoneal Tc-99m MAA, in which a functioning shunt should result in flow to the venous system, with trapping of particles in the lungs. This is preferred over Tc-99m Sulfur-colloid in this setting; the colloid would be taken up in the liver, which might be more easily obscured by the tracer residing in the peritoneum.

References:

Hyde G, Dillon M and Bivins B. Peritoneal Venous Shunting for Ascites: A 15-year perspective. The American Surgeon. 48. 123-127. 1982.

Lund R and Moritz M. Complications of Denver Peritoneovenous Shunting. Arch Surg. 117. 924-928. 1982.

Smith D, Weaver D and Bouwman D. Peritoneovenous shunt (PVS) for malignant ascites. The American Surgeon. 55. 445-449. 1989.

Followup:

The patient was found to have a fibrin sheath at the venous end of the catheter. An attempt was made to disolve this fibrin by enzyme adminstration (Abbokinase), but this was not successful.

The patient then underwent surgical repair of the venous end of the catheter, and flow was restored.

Differential Diagnosis List

Lack of m.a.a. uptake by lungs is consistent with obstruction of the Denver shunt (peritoneal-venous shunt).

ACR Codes and Keywords:

References and General Discussion of Peritoneal Shunt Scintigraphy (Anatomic field:Gasterointestinal System, Category:Misc)

Search for similar cases.

Edit this case

Add comments about this case

Read comments about this case

Return to the Teaching File home page.

Case number: ps003

Copyright by Wash U MO