CASE REPORTS
Bacterial Peritonitis in Patients With Ventriculoperitoneal Shunt By George
Tchirkow
and
Cleveland,
0 Bacterial peritonitis is an unusual complication of ventricutoperitoneal (VP1 shunt for hydrocephalus. This complication, usually associated with peritoneal cysts or perforated viscus. may occur as the first manifestation of shunt infection. Early recognition of this form of bacterial peritonitis and appropriate antibiotic therapy may avert major abdominal surgery in selected cases. INDEX WORDS: Hydrocephalus; toneal shunt; bacterial peritonitis.
ventriculoperi-
V
ENTRICULOPERITONEAL (VP) shunting is presently a popular and relatively successful method of managing hydrocephalus. While the use of Silastic catheters has lessened the incidence of peritoneal complications in this procedure, such complications as perforation of a viscus,’ ascites, and simulated appendicitis” have been reported with increasing frequency in the surgical literature. Bacterial peritonitis appears to occur very infrequently, despite a high incidence of infection in the various complications of VP shunt. In this paper, we report such a case of bacterial peritonitis in a child with VP shunt. The etiology of this form of peritonitis, and nonoperative alternatives in management, are presented as well. CASE
REPORT
At 7 mo of age, this female child was evaluated for head enlargement and was found to have hydrocephalus with severe aqueductal stenosis. A right ventriculoatrial (VA) shunt was placed, which was complicated by postoperative fever. Siap!ryococrus epidprmidis was cultured from the skin incision, and E. co/i grew from a urine specimen. The fever cleared promptly on intravenous methacillin (Staphcillin) and gentamicin (Garamycin) therapy. Two months
Arie
D. Verhagen
Ohio
later, the patient was readmitted for persistent fever and chills. Blood and cerebrospinal fluid (CSF) cultures were positive for S. epidermidis. The patient received intravenous methicillin and gentamicin for 7 days. with clinical improvement and repeatedly sterile blood and CSF cultures. She remained well for approximately 2 yr, until she again developed fever and chills, associated with grunting respirations. S. epidermidis was again cultured from the CSF. After 5 days of appropriate therapy, the ventriculoatrial shunt was removed and a right VP shunt was placed without incident. One month following placement of the VP shunt, the patient was admitted with fever, vomiting, and colicky abdominal pain of 24-hr duration. On examination, the abdomen was distended, with moderate tenderness to direct pressure in all quadrants. Bowel sounds were present but hypoactive. Rectal examination was normal. The WBC count was 15,300 cells per mm:’ A lumbar puncture revealed clear CSF with I 2 WBC per high power field. A plain abdominal film demonstrated small bowel distention in the left upper quadrant, with air-fluid levels. A barium enema on the second hospital day revealed a normal colon and patent appendiceal lumen. Vomiting and abdominal distention persisted, and abdominal exploration was performed for suspected mechanical small bowel obstruction. A diffuse, fibrinous peritonitis was found, with the most severe reaction at sites adjacent to the catheter along the left gutter. There was no mechanical obstruction, nor was there evidence of perforation of a viscus. A Gram stain of the peritoneal fluid revealed Gram-positive cocci. Clear CSF could easily be expressed from the end of the catheter, which was moved to the right side of the peritoneal cavity. Following copious irrigation with warm saline, the abdomen was closed in layers. Postoperative care included intravenous antibiotics (methicillin and gentamicin) and nasogastric suction. By the fourth postoperative day, bowel function had returned, the patient was afebrile and tolerating oral feedings. Cultures of the peritoneal fluid revealed a pure growth of S. epidermidb. The child has had no further abdominal symptoms since surgery. However, sepsis and positive CSF cultures have recurred, requiring removal of the catheter and placement of a new VP shunt. COMMENT
From the Cleveland Clinic Foundation, Cleveland, Ohio, and The Children’s Medical Center, Dayion, Ohio. Address reprint requests to George Tchirkow. M.D., Fellow Doctor, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland,
Ohio 44106.
cc?1978 by Grune & Stratton. 0022-3468/79/l
182
Inc.
402-0016801.00/0
The peritoneal inflammation was more severe than would have been suspected by the physical findings. The low virulance of S. epidermidis probably explains this discrepancy, as well as the 1 mo interval between shunt placement and the development of peritonitis.
Journal of Pediatric Surgery, Vol. 14, No. 2 (April), 1979
BACTERIAL PERITONITIS
IN VP SHUNT
DISCUSSION
Various forms of peritoneal reaction have been reported in patients with VP catheters. Peritoneal cysts containing CSF appear to be the most common expression of peritoneal inflammation. In three cases of large peritoneal cysts reported by Fischer and Shi11ito,4infection or previous abdominal surgery were suggested as etiologic factors. In all three cases, an abdominal mass was palpable and there was clinical evidence of increased intracranial pressure. In 2 of the 3 cases, previous episodes of shunt infection were noted. Clear fluid was found in the cysts of all patients, but bacteriologic studies of the fluid were not presented, nor was information presented regarding the use of antibiotics. Staphylococcus aureus, coagulase-negative, was isolated from a peritoneal cyst on 1 of 4 patients with this complication reported by Parry.5 The cyst fluid of the other patients was sterile, although high doses of antibiotics had been used in these cases. In this report, emphasis was placed on the inflamed intestinal serosal surfaces, which formed the walls of pseudocysts, rather than true cysts. The authors proposed that the inflammation around the catheter tip was due to primary shunt infection and low-grade bacterial peritonitis. Guiterrez and Raimondi6 have reported eleven cases of peritoneal cysts in patients with VP shunts. Eight of the patients had a history of CSF infection prior to cyst formation and most had had multiple shunt revisions. The cyst contents were infected in five patients, with S. epidermidis as the sole organism in all infections, except for one instance of E. coli in cyst fluid. These patients presented uniformly with abdominal distress. Peritonitis, abdominal abscess, and appendicitis were tentative diagnoses prior to discovery of the peritoneal cyst(s). Bacterial peritonitis, in the absence of cysts, is a very unusual complication of VP shunts. In a review of 45 cases of intra-abdominal complications of VP shunts, Grosfeld7 reported one case of peritonitis due to rupture of an infected peritoneal cyst. Peritonitis or ventriculitis due to perforation of a viscus (colon and bladder) were described in a total of seven additional cases. Other intra-abdominal complications in-
183
cluded inguinal hernia formation, intestinal obstruction and extrusion of the VP shunt into the scrotum. Perforation of the bowel by the catheter, with ensuing Gram-negative peritonitis, has also been reported by Sells and Loeser.’ These authors concluded that “an obscure fever in patients with a ventriculoperitoneal shunt should suggest the possibility of shunt-associated, low-grade peritonitis.” In our present case, bacteria1 peritonitis developed in a setting similar to the reported cases of peritoneal cyst. The child had had multiple shunt revisions, as well as prior CSF infection by S. epidermidis, although shunt dysfunction was not evident. There was no history of prior abdominal surgery, other than the original placement of the peritoneal catheter. Despite a diffuse inflammation within the peritoneum, the patient was not toxic and had only moderately elevated temperature and WBC. Rebound abdominal tenderness was absent. These observations suggest that patients with VP shunt and abdominal pain should be placed immediately on antistaphylococcal antibiotics. Neurologic alteration, suggesting shunt dysfunction, or a history of prior shunt infection, would strengthen a tentative diagnosis of peritonitis, possibly associated with peritoneal cyst formation. Frequent abdominal examination, coupled with x-rays and laboratory studies, should allow the physician to monitor the progress of conservative therapy. In children, barium enema may be helpful in excluding acute appendicitis and ileocolic intussusception.” Immediate exploration is indicated if systemic toxicity develops, or if findings suggest the strong possiblity of an intra-abdominal catastrophe, such as a perforated viscus or volvu1us. Unfortunately, ultimate shunt dysfunction appears to be inevitable in these patients. The appropriate use of antibiotics, however, could obviate the need for major abdominal surgery in certain cases if bacteria1 peritonitis is recognized. REFERENCES 1. Sells CJ and Loeser JD: Peritonitis
following perforation of the small bowel: A rare complication of a VP shunt. J Pediatr 83:823-814, 1973 2. Dean DF and Keller EB: Cerebrospinal fluid ascites: A complication of ventriculoperitoneal shunt. J Neural Neurosurg Psychiatry 35:474-476, 1972
184
3. Leibrock L, Baker R, Uematsa S: Simulated acute appendicitis secondary to a ventriculoperitoneal shunt. Surg Neural 4:481-482, 1975 4. Fischer EG and Shillito J: Large abdominal cysts: A complication of peritoneal shunts. Report of three cases. J Neurosurg 31:441-444, 1969 5. Parry SW, Schumacher JF, Llewellyn RC: Abdominal pseudocysts and ascites formation after ventriculoperitoneal shunt procedures. Report of four cases. J Neurosurg 43:476-480, 1975
TCHIRKOW
AND
VERHAGEN
6. Gutierrez FA, Raimondi AJ: Peritoneal cysts: A complication of ventriculoperitoneal shunts. Surgery 79:188-192. 1976 7. Grosfeld JL, Cooney DR, Smith J, et al: Intra-abdominal complications following ventriculoperitoneal procedures. Pediatrics 54:791-796, 1974 8. Jona J. Belin RP, Selka AC: Barium enema as a diagnostic aid in children with abdominal pain. Surg Gynecol Obstet 144:351 355, 1977
Bacterial Peritonitis in Patients With Ventriculoperitoneal Shunt By George
Tchirkow
and
Cleveland,
0 Bacterial peritonitis is an unusual complication of ventricutoperitoneal (VP1 shunt for hydrocephalus. This complication, usually associated with peritoneal cysts or perforated viscus. may occur as the first manifestation of shunt infection. Early recognition of this form of bacterial peritonitis and appropriate antibiotic therapy may avert major abdominal surgery in selected cases. INDEX WORDS: Hydrocephalus; toneal shunt; bacterial peritonitis.
ventriculoperi-
V
ENTRICULOPERITONEAL (VP) shunting is presently a popular and relatively successful method of managing hydrocephalus. While the use of Silastic catheters has lessened the incidence of peritoneal complications in this procedure, such complications as perforation of a viscus,’ ascites, and simulated appendicitis” have been reported with increasing frequency in the surgical literature. Bacterial peritonitis appears to occur very infrequently, despite a high incidence of infection in the various complications of VP shunt. In this paper, we report such a case of bacterial peritonitis in a child with VP shunt. The etiology of this form of peritonitis, and nonoperative alternatives in management, are presented as well. CASE
REPORT
At 7 mo of age, this female child was evaluated for head enlargement and was found to have hydrocephalus with severe aqueductal stenosis. A right ventriculoatrial (VA) shunt was placed, which was complicated by postoperative fever. Siap!ryococrus epidprmidis was cultured from the skin incision, and E. co/i grew from a urine specimen. The fever cleared promptly on intravenous methacillin (Staphcillin) and gentamicin (Garamycin) therapy. Two months
Arie
D. Verhagen
Ohio
later, the patient was readmitted for persistent fever and chills. Blood and cerebrospinal fluid (CSF) cultures were positive for S. epidermidis. The patient received intravenous methicillin and gentamicin for 7 days. with clinical improvement and repeatedly sterile blood and CSF cultures. She remained well for approximately 2 yr, until she again developed fever and chills, associated with grunting respirations. S. epidermidis was again cultured from the CSF. After 5 days of appropriate therapy, the ventriculoatrial shunt was removed and a right VP shunt was placed without incident. One month following placement of the VP shunt, the patient was admitted with fever, vomiting, and colicky abdominal pain of 24-hr duration. On examination, the abdomen was distended, with moderate tenderness to direct pressure in all quadrants. Bowel sounds were present but hypoactive. Rectal examination was normal. The WBC count was 15,300 cells per mm:’ A lumbar puncture revealed clear CSF with I 2 WBC per high power field. A plain abdominal film demonstrated small bowel distention in the left upper quadrant, with air-fluid levels. A barium enema on the second hospital day revealed a normal colon and patent appendiceal lumen. Vomiting and abdominal distention persisted, and abdominal exploration was performed for suspected mechanical small bowel obstruction. A diffuse, fibrinous peritonitis was found, with the most severe reaction at sites adjacent to the catheter along the left gutter. There was no mechanical obstruction, nor was there evidence of perforation of a viscus. A Gram stain of the peritoneal fluid revealed Gram-positive cocci. Clear CSF could easily be expressed from the end of the catheter, which was moved to the right side of the peritoneal cavity. Following copious irrigation with warm saline, the abdomen was closed in layers. Postoperative care included intravenous antibiotics (methicillin and gentamicin) and nasogastric suction. By the fourth postoperative day, bowel function had returned, the patient was afebrile and tolerating oral feedings. Cultures of the peritoneal fluid revealed a pure growth of S. epidermidb. The child has had no further abdominal symptoms since surgery. However, sepsis and positive CSF cultures have recurred, requiring removal of the catheter and placement of a new VP shunt. COMMENT
From the Cleveland Clinic Foundation, Cleveland, Ohio, and The Children’s Medical Center, Dayion, Ohio. Address reprint requests to George Tchirkow. M.D., Fellow Doctor, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland,
Ohio 44106.
cc?1978 by Grune & Stratton. 0022-3468/79/l
182
Inc.
402-0016801.00/0
The peritoneal inflammation was more severe than would have been suspected by the physical findings. The low virulance of S. epidermidis probably explains this discrepancy, as well as the 1 mo interval between shunt placement and the development of peritonitis.
Journal of Pediatric Surgery, Vol. 14, No. 2 (April), 1979
BACTERIAL PERITONITIS
IN VP SHUNT
DISCUSSION
Various forms of peritoneal reaction have been reported in patients with VP catheters. Peritoneal cysts containing CSF appear to be the most common expression of peritoneal inflammation. In three cases of large peritoneal cysts reported by Fischer and Shi11ito,4infection or previous abdominal surgery were suggested as etiologic factors. In all three cases, an abdominal mass was palpable and there was clinical evidence of increased intracranial pressure. In 2 of the 3 cases, previous episodes of shunt infection were noted. Clear fluid was found in the cysts of all patients, but bacteriologic studies of the fluid were not presented, nor was information presented regarding the use of antibiotics. Staphylococcus aureus, coagulase-negative, was isolated from a peritoneal cyst on 1 of 4 patients with this complication reported by Parry.5 The cyst fluid of the other patients was sterile, although high doses of antibiotics had been used in these cases. In this report, emphasis was placed on the inflamed intestinal serosal surfaces, which formed the walls of pseudocysts, rather than true cysts. The authors proposed that the inflammation around the catheter tip was due to primary shunt infection and low-grade bacterial peritonitis. Guiterrez and Raimondi6 have reported eleven cases of peritoneal cysts in patients with VP shunts. Eight of the patients had a history of CSF infection prior to cyst formation and most had had multiple shunt revisions. The cyst contents were infected in five patients, with S. epidermidis as the sole organism in all infections, except for one instance of E. coli in cyst fluid. These patients presented uniformly with abdominal distress. Peritonitis, abdominal abscess, and appendicitis were tentative diagnoses prior to discovery of the peritoneal cyst(s). Bacterial peritonitis, in the absence of cysts, is a very unusual complication of VP shunts. In a review of 45 cases of intra-abdominal complications of VP shunts, Grosfeld7 reported one case of peritonitis due to rupture of an infected peritoneal cyst. Peritonitis or ventriculitis due to perforation of a viscus (colon and bladder) were described in a total of seven additional cases. Other intra-abdominal complications in-
183
cluded inguinal hernia formation, intestinal obstruction and extrusion of the VP shunt into the scrotum. Perforation of the bowel by the catheter, with ensuing Gram-negative peritonitis, has also been reported by Sells and Loeser.’ These authors concluded that “an obscure fever in patients with a ventriculoperitoneal shunt should suggest the possibility of shunt-associated, low-grade peritonitis.” In our present case, bacteria1 peritonitis developed in a setting similar to the reported cases of peritoneal cyst. The child had had multiple shunt revisions, as well as prior CSF infection by S. epidermidis, although shunt dysfunction was not evident. There was no history of prior abdominal surgery, other than the original placement of the peritoneal catheter. Despite a diffuse inflammation within the peritoneum, the patient was not toxic and had only moderately elevated temperature and WBC. Rebound abdominal tenderness was absent. These observations suggest that patients with VP shunt and abdominal pain should be placed immediately on antistaphylococcal antibiotics. Neurologic alteration, suggesting shunt dysfunction, or a history of prior shunt infection, would strengthen a tentative diagnosis of peritonitis, possibly associated with peritoneal cyst formation. Frequent abdominal examination, coupled with x-rays and laboratory studies, should allow the physician to monitor the progress of conservative therapy. In children, barium enema may be helpful in excluding acute appendicitis and ileocolic intussusception.” Immediate exploration is indicated if systemic toxicity develops, or if findings suggest the strong possiblity of an intra-abdominal catastrophe, such as a perforated viscus or volvu1us. Unfortunately, ultimate shunt dysfunction appears to be inevitable in these patients. The appropriate use of antibiotics, however, could obviate the need for major abdominal surgery in certain cases if bacteria1 peritonitis is recognized. REFERENCES 1. Sells CJ and Loeser JD: Peritonitis
following perforation of the small bowel: A rare complication of a VP shunt. J Pediatr 83:823-814, 1973 2. Dean DF and Keller EB: Cerebrospinal fluid ascites: A complication of ventriculoperitoneal shunt. J Neural Neurosurg Psychiatry 35:474-476, 1972
184
3. Leibrock L, Baker R, Uematsa S: Simulated acute appendicitis secondary to a ventriculoperitoneal shunt. Surg Neural 4:481-482, 1975 4. Fischer EG and Shillito J: Large abdominal cysts: A complication of peritoneal shunts. Report of three cases. J Neurosurg 31:441-444, 1969 5. Parry SW, Schumacher JF, Llewellyn RC: Abdominal pseudocysts and ascites formation after ventriculoperitoneal shunt procedures. Report of four cases. J Neurosurg 43:476-480, 1975
TCHIRKOW
AND
VERHAGEN
6. Gutierrez FA, Raimondi AJ: Peritoneal cysts: A complication of ventriculoperitoneal shunts. Surgery 79:188-192. 1976 7. Grosfeld JL, Cooney DR, Smith J, et al: Intra-abdominal complications following ventriculoperitoneal procedures. Pediatrics 54:791-796, 1974 8. Jona J. Belin RP, Selka AC: Barium enema as a diagnostic aid in children with abdominal pain. Surg Gynecol Obstet 144:351 355, 1977
