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Abscess of the falciform ligament in a child with a ventriculoperitoneal shunt
A b s c e s s of the F a l c i f o r m L i g a m e n t in a Child W i t h a Ventriculoperitoneal Shunt By Samuel S. Laucks, II, Thomas V.N. Ballantine, and Danielle K. Boal
York and Hershey, Pennsylvania 9 Falciform ligament abscess resulting from an infected ventriculoperitoneal shunt has not previously been described. This unusual type of abscess should be considered in a patient with an infected ventriculoperitoneal shunt w h o presents with epigastric tenderness. Signs of peritonitis may not be present if the abscess is localized. Imaging studies such as ultrasound or CT scan may frequently establish the diagnosis. 9 1 9 8 6 by Grune & S t r a t t o n . Inc. INDEX W O R D S : Falciform ligament abscess; ventriculoperitoneal shunt.
NTRA-ABDOMINAL
complications resulting
from ventriculoperitoneal shunts have been Ireported. In the present case, we report a falciform ligament abscess developed in a child with a ventriculoperitoneal shunt. CASE REPORT D.N. is a 2~/2-year-old white male with malignant astrocytoma of the third ventricle. At the age of 2 years, he had an open biopsy and insertion of a ventriculoperitoneal shunt. He was treated with radiation therapy. Five months later he presented with a 2-day history of lethargy, irritability, nausea, vomiting, and diarrhea. He had a fever of 40.3 ~ His pulse rate was 160, his respiratory rate was 44, and his blood pressure was 100 systolic. On examination, he had erythema, warmth and tenderness along his shunt tract, as well as epigastric tenderness. His white blood count was 14,800 with 37% neutrophils, 49% bands, and 3% lymphocytes. Vancomycin was started and the abdominal portion of the shunt was exteriorized. Cerebrospinal fluid cultures were positive for more than 100 colonies of Staphloeoccus aureus, sensitive to cephalothin, clindamycin, erythromycin, and oxacillin. Abdominal ultrasound showed fluid lateral and anterior to the right lobe of the liver, and into the anterior midline down to the level of the umbilicus (Figs 1 and 2). Abdominal exploration was performed. A discrete abscess was found within the substance of the falciform ligament. This did not appear to communicate with the peritoneal cavity. The ligament was excised and the abscess cavity was drained. Additionally, an abscess was found in the subhepatic region with pus tracking laterally and posteriorly around the liver. The cultures from these abscesses, like those from the cerebrospinal fluid, were positive for Staphlococcus aureus, and the spectra of sensitivities were exactly the same. Postoperatively, the patient's fever resolved. A follow-up ultrasound showed no evidence of intra-abdominal fluid.
DISCUSSION
The falciform ligament extends from the umbilicus upward to the diaphragm where the two peritoneal layers divide and extend laterally as parts of the coronary ligaments of the liver. A potential space is present within the ligament. 1 Within this space lies the Journal of Pediatric Surgery, Vol 21, No 11 (November), 1986: pp 979-980
round ligament, paraumbilical veins, adipose tissue, and a few muscle fibers. 2 Various pathologic conditions of the falciform ligament have been described. For instance, cysts have been reported to occur within the ligament. Congenital cysts have an obscure embryology. Infectious, usually echinococcal, cysts have been described. Additionally, traumatic cysts filled with liquified hematoma, and bile-filled cysts secondary to biliary tract extravasation, are known to occur. 2 Webber et al 3 describe a 30-year-old woman who presented with epigastric pain and a tender epigastric mass, secondary to torsion of the ligament with infarction. Two cases of falciform ligament abscesses were found in the literature. ~'4 In both cases, the abscesses were secondary to cholecystitis of long duration. One of these patients presented in shock with diffuse abdominal tenderness and rigidity, and the other with a tender epigastric mass. In the latter case, the abscess was delineated by CT scan and by ultrasound. 1 One other case, cited in Doscher's paper, was reported in the Russian literature (cited in reference 4). This patient of unknown age had suppurative thrombophlebitis of the umbilical vein with a phlegmon of the round ligament. 4 In the present case, the most likely source of infection of the ligament was his infected ventriculoperitoneal shunt. Pus was expressed from the subcutaneous tract, and the same organism was cultured from both the cerebrospinal fluid and the abdominal abscesses. We cannot describe with certainty the exact path of the contamination, since the distal portion of the shunt was exteriorized prior to the laparotomy. However, since the shunt passed immediately beside the ligament, seeding probably occurred by direct contamination. Support for this concept may be derived from a case reported by Rodgers et al s in which the distal tip of the shunt was actually entrapped within the falciform ligament. Our patient also had a collection of pus in the
From the Department of Surgery, York Hospital, York, PA, and the Divisions of Pediatric Surgery and Pediatric Radiology, The Milton S. Hershey Medical Center, Hershey, PA. Address reprint requests to Thomas V.N. Ballantine, MD, Pediatric Surgery Division, University Hospital, Box 850, Hershey, PA 17033. 9 1986 by Grune & Stratton, Inc. 0022 3468/86/2111-0027503.00/0 979
980
LAUCKS, BALLANTINE, AND BOAL
Fig 1. Ultrasound, transverse projection, demonstrating subhepatic abscess (SH) and falciform ligament abscess (FL).
subhepatic region. T h o u g h it is possible that the infection tracked along the tissue planes to invade the falciform ligament by direct extension, such a c o m m u nication was not evident at the time of surgery. N o n e of the pus found at the time of exploration was free within the peritoneal cavity. As a result, the patient did not have physical signs of peritonitis. It requires a strong index of suspicion to make the diagnosis of falciform ligament abscess preoperatively. A confined abscess should present as an area of tenderness, or possibly as a tender mass, in the epigastrium. ~ Spiking fevers and leukocytosis may raise suspicion of an abscess. Although these two findings were present in our patient, they were absent in the other two cases cited in the literature. 1'4 Ultrasound or C T scan should be helpful in evaluating the patient and in establishing the timing for drainage. The appropriate treatment of falciform ligament
Fig 2. Ultrasound. left posterior oblique projection, demonstrating subhepatic abscess (SH), faiciform ligament abscess (FL), and gall bladder (GB).
abscess consists of excision of the ligament and establishment of adequate drainage of the abscess. 4 REFERENCES
1. Sones PJ, Thomas BM, Masand PP: Falciform ligament abscess: Appearance on computed tomography and sonography. AJR137:161 162, 1981 2. Gondring WH: Solitary cyst of the falciform ligament of the liver: Report of a case and review of the literature. Am J Surg 109:526-529, 1965 3. Webber CE, Gtanges E, Crenshaw CA: Falciform ligament: A possible twist? Arch Surg 112:1264, 1977 4. Doscher W, Chardavoyne R, Teicher I: Abscess of the falciform ligament: Acute abdominal syndrome of obscure etiology. NY State J Med 1131-1133, 1980 5. Rodgers BM, Vries JK, Talbert JL: Laparoscopy in the diagnosis and treatment of malfunctioning ventriculoperitoneal shunts in children. J Pediatr Surg 13:247-253, 1978
York and Hershey, Pennsylvania 9 Falciform ligament abscess resulting from an infected ventriculoperitoneal shunt has not previously been described. This unusual type of abscess should be considered in a patient with an infected ventriculoperitoneal shunt w h o presents with epigastric tenderness. Signs of peritonitis may not be present if the abscess is localized. Imaging studies such as ultrasound or CT scan may frequently establish the diagnosis. 9 1 9 8 6 by Grune & S t r a t t o n . Inc. INDEX W O R D S : Falciform ligament abscess; ventriculoperitoneal shunt.
NTRA-ABDOMINAL
complications resulting
from ventriculoperitoneal shunts have been Ireported. In the present case, we report a falciform ligament abscess developed in a child with a ventriculoperitoneal shunt. CASE REPORT D.N. is a 2~/2-year-old white male with malignant astrocytoma of the third ventricle. At the age of 2 years, he had an open biopsy and insertion of a ventriculoperitoneal shunt. He was treated with radiation therapy. Five months later he presented with a 2-day history of lethargy, irritability, nausea, vomiting, and diarrhea. He had a fever of 40.3 ~ His pulse rate was 160, his respiratory rate was 44, and his blood pressure was 100 systolic. On examination, he had erythema, warmth and tenderness along his shunt tract, as well as epigastric tenderness. His white blood count was 14,800 with 37% neutrophils, 49% bands, and 3% lymphocytes. Vancomycin was started and the abdominal portion of the shunt was exteriorized. Cerebrospinal fluid cultures were positive for more than 100 colonies of Staphloeoccus aureus, sensitive to cephalothin, clindamycin, erythromycin, and oxacillin. Abdominal ultrasound showed fluid lateral and anterior to the right lobe of the liver, and into the anterior midline down to the level of the umbilicus (Figs 1 and 2). Abdominal exploration was performed. A discrete abscess was found within the substance of the falciform ligament. This did not appear to communicate with the peritoneal cavity. The ligament was excised and the abscess cavity was drained. Additionally, an abscess was found in the subhepatic region with pus tracking laterally and posteriorly around the liver. The cultures from these abscesses, like those from the cerebrospinal fluid, were positive for Staphlococcus aureus, and the spectra of sensitivities were exactly the same. Postoperatively, the patient's fever resolved. A follow-up ultrasound showed no evidence of intra-abdominal fluid.
DISCUSSION
The falciform ligament extends from the umbilicus upward to the diaphragm where the two peritoneal layers divide and extend laterally as parts of the coronary ligaments of the liver. A potential space is present within the ligament. 1 Within this space lies the Journal of Pediatric Surgery, Vol 21, No 11 (November), 1986: pp 979-980
round ligament, paraumbilical veins, adipose tissue, and a few muscle fibers. 2 Various pathologic conditions of the falciform ligament have been described. For instance, cysts have been reported to occur within the ligament. Congenital cysts have an obscure embryology. Infectious, usually echinococcal, cysts have been described. Additionally, traumatic cysts filled with liquified hematoma, and bile-filled cysts secondary to biliary tract extravasation, are known to occur. 2 Webber et al 3 describe a 30-year-old woman who presented with epigastric pain and a tender epigastric mass, secondary to torsion of the ligament with infarction. Two cases of falciform ligament abscesses were found in the literature. ~'4 In both cases, the abscesses were secondary to cholecystitis of long duration. One of these patients presented in shock with diffuse abdominal tenderness and rigidity, and the other with a tender epigastric mass. In the latter case, the abscess was delineated by CT scan and by ultrasound. 1 One other case, cited in Doscher's paper, was reported in the Russian literature (cited in reference 4). This patient of unknown age had suppurative thrombophlebitis of the umbilical vein with a phlegmon of the round ligament. 4 In the present case, the most likely source of infection of the ligament was his infected ventriculoperitoneal shunt. Pus was expressed from the subcutaneous tract, and the same organism was cultured from both the cerebrospinal fluid and the abdominal abscesses. We cannot describe with certainty the exact path of the contamination, since the distal portion of the shunt was exteriorized prior to the laparotomy. However, since the shunt passed immediately beside the ligament, seeding probably occurred by direct contamination. Support for this concept may be derived from a case reported by Rodgers et al s in which the distal tip of the shunt was actually entrapped within the falciform ligament. Our patient also had a collection of pus in the
From the Department of Surgery, York Hospital, York, PA, and the Divisions of Pediatric Surgery and Pediatric Radiology, The Milton S. Hershey Medical Center, Hershey, PA. Address reprint requests to Thomas V.N. Ballantine, MD, Pediatric Surgery Division, University Hospital, Box 850, Hershey, PA 17033. 9 1986 by Grune & Stratton, Inc. 0022 3468/86/2111-0027503.00/0 979
980
LAUCKS, BALLANTINE, AND BOAL
Fig 1. Ultrasound, transverse projection, demonstrating subhepatic abscess (SH) and falciform ligament abscess (FL).
subhepatic region. T h o u g h it is possible that the infection tracked along the tissue planes to invade the falciform ligament by direct extension, such a c o m m u nication was not evident at the time of surgery. N o n e of the pus found at the time of exploration was free within the peritoneal cavity. As a result, the patient did not have physical signs of peritonitis. It requires a strong index of suspicion to make the diagnosis of falciform ligament abscess preoperatively. A confined abscess should present as an area of tenderness, or possibly as a tender mass, in the epigastrium. ~ Spiking fevers and leukocytosis may raise suspicion of an abscess. Although these two findings were present in our patient, they were absent in the other two cases cited in the literature. 1'4 Ultrasound or C T scan should be helpful in evaluating the patient and in establishing the timing for drainage. The appropriate treatment of falciform ligament
Fig 2. Ultrasound. left posterior oblique projection, demonstrating subhepatic abscess (SH), faiciform ligament abscess (FL), and gall bladder (GB).
abscess consists of excision of the ligament and establishment of adequate drainage of the abscess. 4 REFERENCES
1. Sones PJ, Thomas BM, Masand PP: Falciform ligament abscess: Appearance on computed tomography and sonography. AJR137:161 162, 1981 2. Gondring WH: Solitary cyst of the falciform ligament of the liver: Report of a case and review of the literature. Am J Surg 109:526-529, 1965 3. Webber CE, Gtanges E, Crenshaw CA: Falciform ligament: A possible twist? Arch Surg 112:1264, 1977 4. Doscher W, Chardavoyne R, Teicher I: Abscess of the falciform ligament: Acute abdominal syndrome of obscure etiology. NY State J Med 1131-1133, 1980 5. Rodgers BM, Vries JK, Talbert JL: Laparoscopy in the diagnosis and treatment of malfunctioning ventriculoperitoneal shunts in children. J Pediatr Surg 13:247-253, 1978