Hrev_master Emergency Care Journal 2018; volume 14:7433 Case presentation A 27-year-old female presented to the emergency department with approximately eight hours of abdominal pain, nausea and vomiting, and abdominal wall swelling. She denied fevers or chills, or any recent history of abdominal trauma. She recently had a ventriculoperitoneal (VP) shunt placed six weeks ago for a cere- brospinal fluid leak with recurrent headaches associated with a Chiari 1 malformation. She was mildly tachycardic, with otherwise normal vital signs. Physical exam revealed a subcutaneous fluid collection measuring approximately 10 cm × 10 cm with mild associated erythema in the right upper quadrant near her postoper- ative site. Bedside ultrasound revealed a hypoechoic fluid collection sur- rounding a tubular foreign body found to be the patient’s malposi- tioned VP shunt, which had externalized through her peritoneum and abdominal muscles (Figure 1). In the operating room, this shunt was externalized from the abdominal cavity and attached to a drainage bag, and subsequently completely removed several weeks later. Interestingly enough, she had a VP shunt replaced several months later due to worsening headaches, only to have the same repeat complication of abdominal wall perforation. At that time, the emergency physician used a CT scan for evaluation of her com- plication (Figure 2). Correspondence: Joe Betcher, Mercy Health Partners, 49444 Muskegon, MI, USA. Tel.: 616.403.6908 - Fax: 231.727.5223. E-mail: joebetcher@gmail.com Key words: Ultrasound; Bedside; Education; Ventriculoperitoneal. Contributions: all authors were present when obtaining the bedside ultrasound images in the clinical setting. JBe drafted the original manu- script, while RK provided multiple revisions to the manuscript. JBi obtained and edited images for appropriate quality. All authors reviewed and provided edits for the final copy of the manuscript. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Received for publication: 23 March 2018. Revision received: 19 June 2018. Accepted for publication: 19 June 2018. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright J. Biessel et al., 2018 Licensee PAGEPress, Italy Emergency Care Journal 2018; 14:7433 doi:10.4081/ecj.2018.7433 Suspicion for malpositioned ventriculoperitoneal shunt diagnosed with bedside ultrasound Jay Biessel, Ross Keesling, Joe Betcher Lake Michigan Emergency Specialists, Mercy Health Partners, Muskegon, MI, USA Figure 1. Bedside ultrasound revealing a hypoechoic fluid collec- tion with a tubular foreign body. Figure 2. CT scan of the abdomen and pelvis with large fluid col- lection subcutaneously located in the LUQ, 4.7 × 8.1 mm in size at the largest cross section. [page 78] [Emergency Care Journal 2018; 14:7433] Non -co mmerc ial us e o nly [Emergency Care Journal 2018; 14:7433] [page 79] Diagnosis This patient was diagnosed with a malpositioned VP shunt with abdominal wall fluid collection utilizing bedside ultrasound. There have been prior reports of extrusion of the peritoneal end of the VP shunt, including through the abdominal wall, umbilicus, and anus, all of which are rare complications.1 The pressure of the tip of the catheter on the local abdominal wall or viscera can lead to inflammation and erosion.2 Predisposing factors include infec- tion, tube obstructions and multiple shunt revisions.3 References 1. Birbilis T, Theodoropoulou E, Matis G. Spontaneous external- ization of peritoneal catheter through the abdominal wall in a patient with hydrocephalus: A case report. Cases J 2009;16:6898. 2. Kanojia R, Sinha SK, Rawat J, et al. Unusual ventriculoperi- toneal shunt extrusion: Experience with 5 cases and review of the literature. Pediatr Neurosurg 2008;44:49-51. 3. Mobley L, Doran S, Hellbusch L. Abdominal pseudocyst: pre- disposing factors and treatment algorithm. Pediatr Neurosurg 2005;41:77-83. Images in Emergency Non -co mmerc ial us e o nly