Abdominal complications from peritoneal shunts

GASTROENTEROLOGY

CASE

77:337-340,1979

REPORTS

Abdominal Shunts JOSEPH

Complications

F. NORFRAY,

MARSHALL

HARVEY

from Peritoneal

M. HENRY, JOHN D. GIVENS,

and

S. SPARBERG

The Departments of Radiology and Surgery, Henrotin Hospital, and the Department Medicine, Northwestern Memorial Hospital, Chicago, Illinois

Abdominal complications of peritoneal shunts for hydrocephalus occur infrequently. Pseudocysts, peritonitis, ascites, pseudotumor, and volvuJus have been reported. We are presenting a patient who developed an acute abdomen from a pseudocyst to stress: (o) that abdominal symptoms usually precede the neurologic symptoms; and (b) that the abdominal symptoms can develop from days to years after the shunting procedure.

Hydrocephalus is being managed more frequently with peritoneal shunts.‘-4 Abdominal complications of peritoneal shunts are uncommon, and are scattered in the neurosurgical and radiologic literature. The abdominal symptoms usually appear days or weeks before the neurologic symptoms,5-7 and the intraabdominal abnormality may develop up to 10 yr after the shunting.* We are presenting our patient who developed symptoms of an acute abdomen from a cerebrospinal fluid (CSF) pseudocyst which was diagnosed preoperatively by computed tomography. Chase Report A. 43-year-old female was admitted with severe headaches, nausea, vomiting, and papilledema. Two years previously, she was diagnosed as having idiopathic communicating hydrocephalus, which was initially treated by a ventriculoperitoneal shunt. The shunt became infected and was removed, An admission CT brain scan demonstrated increased ventricular size when compared with a study done 2 yr earlier. A ventriculoperitoneal shunt was placed on the 3rd hospital day (Figure 1 A-C). Nine days after surgery, Received January 2,1979. Accepted February 26.1979. Address requests for reprints to: Joseph F. Norfray, M.D., Department of Radiology, Henrotin Hospital, 111 West Oak Street, Chicago, Illinois 60610. 0 1979 by the American Gastroenterological Association 0016~5065/79/080337-04$02.00

of Internal

she developed pulmonary emboli and was started on anticoagulation. Ten days later she manifested severe right lower quadrant pain, abdominal distention, and pyrexia (100.5’F). Rebound tenderness and decreased bowel sounds were present. Neurologic symptoms were absent. The WBC was normal, while the prothrombin time was twice normal. An abdominal CT scan demonstrated a 5.8 X 6.0 cm oval mass beneath the anterior abdominal wall with the shunting tubing traversing the mass (Figure 2). The CT numbers of the mass were 2-3 Hounsfield units (HU: 1,000scale) indicating water density and not hemorrhage. A contrast study was not obtained because of the history of hives during the previous CT brain scan. The preoperative diagnosis was abscess vs. pseudocyst. A preoperative diagnostic paracentesis was not performed. At surgery, the pseudocyst between the anterior abdominal wall and the omentum was inadvertently entered releasing crystal clear fluid which was under pressure. Analysis of the fluid was not obtained. After excision of the pseudocyst, the shunt tubing was repositioned in a deeper plan in the peritoneal cavity.

Discussion Peritoneal shunts are being used more frequently in the treatment of hydrocephalus because of the increasing number of complications from ventriculovascular shunts, and because of the significantly increased patency rate of the peritoneal shunts using the inert silicone catheters.le4 Over a 5year period, Gutierrez and Raimondi” have created 1,585 peritoneal shunts. The peritoneal cavity provides an excellent absorptive surface for CSF with the CSF being drained from the ventricles (ventriculoperitoneal shunt) or the lumbar subarachnoid space (lumboperitoneal shunt). Because the silicone catheters are radiopaque, the type of peritoneal shunt can easily be differentiated by an abdominal film. The abdominal complications of peritoneal shunts occur infrequently. The spectrum of abdominal complications of peritoneal shunts includes: cere-

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brospinal fluid pseudocysts, peritonitis, cerebrospinal fluid ascites, volvulus, and pseudotumor of the mesentery. The diagnosis and treatment can be delayed when the physician fails to recognize that the abdominal symptoms can arise years after the shunting. Cerebrospinal fluid pseudocysts are the most common abdominal complication with over 25 cases having been reported since l%5.5-‘6 It is considered a pseudocyst, because the walls of the cyst are not composed of mesothelium, but either of fibrous tissue or inflamed intestinal serosal surface.7 The development of a pseudocyst involves a reaction to either the catheter or some component in the draining

GASTROGENTEROLOGY

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cerebrospinal fluid. The location of the pseudocyst depends on the position of the abdominal shunt and has occurred within the abdominal wall,” adjacent to the inner abdominal wall,“’ in the omentum,‘z,14 and throughout the peritoneal cavity. The volume and size of the pseudocysts vary-a volume of more than 1,000 cc and a size greater than 10 cm have been recorded.“.‘D.‘6 The abdominal symptoms of pseudocysts are related to their size from pressure on adjacent structures. Patients can present with abdominal signs and symptoms of: anorexia, pain, abdominal distention, guarding, rebound tenderness, a change in bowel sounds, and very often a palpable mass. The abdom-

August 197'9

ABDOMINAL

COMPLICATIONS

FROM

PERITONEAL

SHUNTS

Figure 2. Abdominal CT scan demonstrating the pseudocyst beneath the anterior abdominal wall (arrowheads). The shunt tubing is within the subcutaneous tissue of the abdominal wall and adjacent to the pseudocyst (arrows). Large letters indicate right (R) side of patient and spine (S).

inal symptoms usually occur before the neurologic symptoms of headache, irritability, or decreased level of consciousness.5-7 Davidson and Lingley presented al patient with abdominal symptoms which antedate neurologic symptoms by 3 mo.5 Vomiting can be caused by either increased pressure on abdominal structures or increased intracranial pressure. A fever may or may not be present. A pseudocyst has developed 10 yr after the shunting.” The diagnosis of pseudocysts has been simplified by computed tomography and ultrasound.9.““3 Computed tomography and ultrasound can exquisitely define the mass with the shunt tubing being within or adjacent to the pseudocyst. Computed tomography cannot differentiate between a sterile or an infected pseudocyst for both will be low density masses which may or may not demonstrate contrast enhancement.9.17 Gutierrez and Raimondi” have advocated preoperative diagnostic paracentesis to determine which pseudocysts are infected. Only one author has recorded the composition of the fluid of a sterile pseudocyst.‘B Analysis revealed 1,980 RRC and 340 WBC with a differential of 85% round cells. Sugar was 33 mg/lOO ml, and protein

was 1,086 mg/lOO ml. Fluid analysis has not been recorded in infected pseudocysts. There are several views on treatment of pseudocyst. Davidson and Lingley aspirate its contents through the abdominal catheter, and then convert the ventriculoperitoneal shunt to a ventriculoatrial shunt, thus preventing a laparotomy.5 Other authors excise the pseudocyst, and either reposition the shunt in the peritoneal cavity6 or convert to another type of shunt.” Peritonitis has occurred in 3 patients.2”R.‘g Symptoms of peritonitis arose without neurologic symptoms; however, E. coli was cultured in the CSF from a ventriculostomy in 1 patient indicating a ventriculitis.‘” The longest interval between the original shunting and the manifestation of peritonitis was 3.5 yr.’ In 2 of the patients, the catheters had become lost in ther peritoneal cavity and were passed per rectum before peritonitis.‘“,‘” Three patients had CSF ascites.‘.7.20 All presented with abdominal distention; neurologic symptoms supervened in only 1 patient 11 mo after the appearance of ascites. In 1 patient the ascites developed 2 yr after the shunting. The peritoneum loses its ab-

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GASTROGENTEROLOGY

sorptive capacity because of inflammatory changes.’ The ascites emerged in the 3 patients following (a) the shunting operation,7 (b) an acute febrile illness,’ and (c) a routine DPT immunization.z0 The single case of volvulus occurred 5 wk after the peritoneal shunt.‘l Symptoms of an acute mechanical bowel obstruction were present, but neurologic symptoms did not materialize. At surgery, the volvulus had occurred about an adhesive band in the region of the tubing. The single inflammatory mesenteric pseudotumor was found at autopsy 29 mo after the shunting.” The patient was free from abdominal and neurologic symptoms and had died from pneumonia plus laryngeal edema. References 1. Ames

RH: Ventriculo-peritoneal shunts in the management hydrocephalus. J Neurosurg 27:525-529,1967 2. Eisenberg HM, Davidson RI, Shillito J Jr: Lumboperitoneal shunts. J Neurosurg 35:427-431,1971 3. Hammon WM: Evaluation and use of the ventriculo-perito-

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neal shunt in hydrocephalus. J Neurosurg 34:792-795,197l 4. Jones RF: Long-term results in various treatments of hydrocephalus. J Neurosurg 26:313-315,1967 RI, Lingley JF: Intraperitoneal pseudocyst: treat5. Davidson ment by aspiration. Surg Neurol4:33-36,1975 FA, Raimondi AJ: Peritoneal cysts: a complication 6. Gutierrez of ventriculoperitoneal shunts. Surgery 79:188-192,1976 Parry SW, Schuhmacher JF, Llewellyn RC: Abdominal pseudocysts and ascites formation after ventriculoperitoneal shunt procedures. J Neurosurg 43:476-480,1975 Murtagh F, Lehman R: Peritoneal shunts in the management of hydrocephalus. JAMA 202:98-102.1967 Chuang VP, Fried AM, Oliff M, et al: Abdominal CSF pseudocyst secondary to ventriculo-peritoneal shunt: diagnosis by

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computed tomography in two cases. J Comput Asst Tomog 288-91, 1978 10. Fischer EG, Shillito J, Jr: Large abdominal cysts: a complication of peritoneal shunts. J Neurosurg 31:441-444.1969 11. Goldfine SL, Turetz F, Beck AR, et al: Cerebrospinal fluid intraperitoneal cyst: an unusual abdominal mass. Am J Roentgen01 130:568-569.1978 12. Jackson IJ, Snodgrass SR: Peritoneal shunts in the treatment of hydrocephalus and increased intracranial pressure. J Neurosurg 12:216-222.1955 13. Lee TG, Parsons PM: Ultrasound diagnosis of cerebrospinal fluid abdominal cyst. Radiology 127:220,1978 14. Parrish RA, Potts JM: Torsion of omental cyst-a rare complication of ventriculoperitoneal shunt. J Pediatr Surg 8:969-970, 1973 15 Scott M, Wycis HT, Murtagh F, et al: Observations on ventricular and lumbar subarachnoid peritoneal shunts in hydrocephalus in infants. J Neurosurg X165-175,1955 16 Sivalingam S, Corkill G, Getzen L, et al: Recurrent abdominal cyst: a complication of ventriculoperitoneal shunt and its management. J Pediatr Surg 11:1029-1030,1976 17. Korobkin M, Callen PW, Filly RA, et al: Comparison of computed tomography, ultrasonography, and gallium-67 scanning in the evaluation of suspected abdominal abscess. Radiology 129:89-93,1978 18. Sells CJ, Loeser JD: Peritonitis following perforation of the bowel: a rare complication of a ventriculoperitoneal shunt. J Pediatr 83:823-824, 1973 19. Wilson CB, Bertan V: Perforation of the bowel complicating peritoneal shunt for hydrocephalus. Am Surg 32601-603, 1966 20. Dean DF, Keller IB: Cerebrospinal fluid ascites: a complication of a ventriculoperitoneal shunt. J Neural Neurosurg Psychiatr 35:474-476.1972 21. Sakoda TH, Maxwell JA, Brackett CE Jr: Intestinal volvulus secondary to a ventriculoperitoneal shunt. J Neurosurg 35:9596,197l 22. Keen PE, Weitzner S: Inflammatory pseudotumor of mesentery: a complication of ventriculoperitoneal shunt. J Neurosurg 38:371-373.1973