Journal of Pediatric Surgery (2006) 41, 1255 – 1258

www.elsevier.com/locate/jpedsurg

Appendicitis in the child with a ventriculo-peritoneal

shunt: a 30-year review
Sigmund H. Eina,*, Steven Millerb, James T. Rutkac
a
Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8
b
Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8
c
Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8

Index words: Abstract

Ventriculoperitoneal
Purpose: Each year, about 270 children are treated at our hospital for appendicitis, and there are 200
shunt;
ventriculo-peritoneal (VP) shunt procedures. The incidence of primary peritonitis after a VP shunt is 8%
Appendicitis
to 12%. The purpose of this article is to try and differentiate these 2 entities.
Methods: From 1973 to 2003 inclusive, appendicitis was diagnosed in 8 children with a VP shunt at our
hospital; there were 7 boys and 1 girl with 5 acute appendicitis and 3 ruptured appendices. The first case
was diagnosed on purely clinical grounds, whereas the last 7 were confirmed by ultrasonography and/or
computed tomography.
Results: All 8 had appendectomy and the shunt was exteriorized in the 3 children with a ruptured
appendix. There were no postoperative problems, and the 8 children remained well.
Conclusion: Acute appendicitis can and does rarely occur in children with VP shunts; however, in such
situations, the correct diagnosis can be confirmed by imaging. The shunt must be temporarily
exteriorized if the appendix is ruptured.
D 2006 Elsevier Inc. All rights reserved.

The purpose of this article is to try and differentiate
between appendicitis and primary peritonitis from a shunt
infection in the pediatric patient with a ventriculo-peritoneal
(VP) shunt.
1. Materials and methods
From 1973 to 2003 inclusive, appendicitis was diagnosed
and treated in 8 children with a VP shunt at The Hospital for
Sick Children (HSC), Toronto, Canada. This study was
approved by the HSC Research Ethics Board.
* Corresponding author. Tel.: +1 416 813 6405; fax: +1 905 576 1735.
E-mail address: a_ein@istar.ca (S.H. Ein).
There were 7 boys and 1 girl from 8 to 17 years old
(Table 1). The history lasted from 12 hours to 10 days
(average, 4 days); all had localized or diffuse peritonitis.
None of these 8 children presented with neurologic
dysfunction or evidence of shunt malfunction. All but one
of the white blood cell counts were above 12,000. The
clinical diagnosis was confirmed by ultrasonography (US)
in 4 and was suspicious in 3 (2 US, 1 plain abdominal x-ray,
and 1 computed tomography [CT]).
2. Results
All 8 patients had an appendectomy as soon as the
diagnosis was made: 5 had acute appendicitis and 3 had

0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2006.03.004
1256
Table 1 Appendicitis in children with VP shunt
Year Age (y) Sex Symptoms
and signs
1 1973 17 M 24 h of anorexia, dysuria, and RLQ pain
2 1986 10 M 2 d of vomiting and RLQ pain
3 1993 10 M 2 d of vomiting and RLQ pain
4 1994 12 1/2 M 12 h of vomiting and RLQ pain
5 1995 10 F 4-5 d of fever and RLQ pain
6 1999 11 M 24 h of RLQ pain, exteriorized VP +
triple antibiotics, 10 d worse
7 2000 8 M 7 d of vomiting and abdominal pain
8 2003 11 1/2 M 2 d of vomiting and abdominal pain
RLQ, right lower quadrant; WBC, white blood cell; PO, postoperative; Amp, ampicillin; Gent, gentamycin; Clox, cloxacillin; Cefox, cefoxitin; Clind,
clindamycin; Triples, ampicillin, clindamycin or flagyl, gentomycin.
ruptured appendices (Table 1). The VP shunt was
exteriorized in the 3 ruptured cases and then replaced in-
to the pleural cavity between 10 and 15 days postopera-
tively. All children had preoperative and postoperative
antibiotics for a minimum of 5 days. None developed a
postoperative cerebrospinal fluid pseudocyst, nor did any
have ascending shunt infections. The follow-up ranges
from 1 to 30 years, and all patients have remained well.
Four children (3 with acute appendicitis and 1 with
ruptured appendices) had 1 to 3 shunt revisions from
3 months to 4 years after appendectomy.
3. Discussion
At HSC, 270 children are treated annually for appendi-
citis (about one third are ruptured) [1], and over the same
period, there are 200 VP shunt procedures (insertions and
revisions) [2]. The infection rate with VP shunts at HSC has
varied from 8% to 12% over the 3 study periods since 1984
[3-5], and our incidence of overall postoperative small-
bowel obstruction because of adhesions is 5% [6]. There-
fore, at HSC, the incidence of a child with appendicitis
having a VP shunt is 1 in 1000, and the chances of a child
with a VP shunt having appendicitis is 1 in 750.
When a child with spina bifida and a VP shunt develops
fever, anorexia, nausea, vomiting, acute abdominal pain,
and right lower quadrant peritoneal signs along with an
elevated white blood cell count, the differential diagnosis is
primary peritonitis because of an infected VP shunt,
appendicitis, or even an adhesive small-bowel obstruction.
The diagnosis of a child with a VP shunt who has an acute
abdomen can be very perplexing [7] because of the
differential diagnoses [8-15]. There are only 12 articles in
S.H. Ein et al.
Abdominal US CT WBC
x-rays
0 0 0 12
Appendicolith, 0 0 16
RLQ ileus
RLQ ileus + appendicolith 0 15
0 + 0 17
RLQ ileus + 0 15
0 Fluid 2 large 10
abscesses
0 RLQ abscess 0 14
0 + 0 24
the English literature since 1967 that report appendicitis in
the pediatric patient with a VP shunt, and none of these
publications had more than 6 cases. During this time, there
were 5 times as many reports about VP shunt complications
that did not mention appendicitis.
Appendicitis has only been diagnosed in children with
VP shunts on 8 occasions at HSC between 1973 and 2003.
There were 2 such cases before the 1990s with the
remaining 6 diagnosed between 1993 and 2003. It is
inexplicable why this sequence has occurred, nor why 7
of the 8 patients were male. At HSC, 8% to 12% of all VP
shunts become infected [4-6], requiring the shunt to be
cultured and treated (usually exteriorized); the commonest
organism causing primary peritonitis from a shunt infection
is Staphylococcus epidermidis [4]. It would be highly
unlikely to miss a case of acute appendicitis because if left
inadequately treated (as in case 6), it would progress to a
rupture causing diffuse peritonitis with gram-negative
organisms. However, it is not to be forgotten that 7% of
VP shunt infections are caused by Escherichia coli [4]. The
dilemma of not making a quick and early diagnosis can
easily be appreciated [8-15], hence, the longer average time
(4 days) to make the diagnosis, leading to a higher incidence
(38%) of a ruptured appendix [11] (Table 1). In retrospect,
the fact that none of our 8 patients had a change in their
neurologic function may have pointed the diagnosis away
from a primary shunt infection and more toward appendi-
citis [4]. Similarly, patients with an infected shunt tend to be
1 year or younger, and most shunt infections tend to occur
soon after (within 3 months) their placement [16]. Neither of
these occurrences were seen in our patients [4].
With the increasing dependence upon radiologic diagno-
sis and confirmation of appendicitis over the last decade, it
is no wonder that the last 6 cases were diagnosed in 4 and
Appendicitis in the child with a ventriculo-peritoneal shunt 1257

Operative Shunt Peritoneal Antibiotics Postoperative Follow-up

finding management culture course
Acute 0 Negative PO Amp and Gent  Home PO, 3 d 1 shunt revision, March
3 d + PO Clox 1974 (PO, 3 mo)
Acute 0 Negative Preoperative Cefox, Home PO, 6 d OK
PO Clind and Gent
Acute 0 E. coli Pre- and postoperative Home PO, 6 d 2 shunt revisions, 1995
Bacteriodes Cefox and 1997 (PO, 2 y)
Acute 0 Negative Preoperative Cefox, Home PO, 5 d 3 shunt revisions,
PO Clind, Gent  5 d 1998 (PO, 4 y)
Ruptured VP exteriorized; Negative Pre- and postoperative Home PO, 13 d 2 shunt revisions, 1995
V pleural; PO, 10 d Triples  10 d and 1999 (PO, 6 m)
Ruptured VP exteriorized; E. coli PO Triples  10 d Home PO, 3 wk OK
V pleural; PO, 10 d
Ruptured VP exteriorized; Negative PO triples  10 d Home PO, 3 wk OK
V pleural; PO, 15 d
Acute 0 Negative Pre- and postoperative Home PO, 5 d OK
Triples  5 d

suspected in 2 by US [17,18] and 1 by CT; the clinical
diagnosis of acute appendicitis may indeed be a disappear-
ing art.
The standard therapy in such situations of acute
appendicitis in the presence of a VP shunt is to remove
the appendix and leave the shunt in place [8]; however, there
is no unanimous opinion in the literature about what to do
for antibiotic coverage—prophylaxis or therapeutic [11,15].
On the other hand, in cases of ruptured appendicitis, not
only should the appendix be removed, but most authors also
feel that the shunt requires exteriorization [10,19], and the
standard pre- and postoperative triple antibiotic treatment as
usual should be implemented [20]. Whether laparoscopic
surgery will change this approach remains to be seen [21].
There were no postoperative cerebrospinal fluid collec-
tions or ascending shunt infections in this series. This tends
to agree with the literature with most authors claiming that
primary intraabdominal disease (such as appendicitis)
requires surgical treatment, during which the shunt system
can probably be left in place [9-11,13,15].
When to replace the exteriorized shunt back into the
body and/or peritoneal cavity is, however, somewhat
speculative [10,11,19]; in our 3 ruptured cases, the
exteriorized shunt was replaced into the pleural cavity
within 2 weeks. In the first (1973) case, although not
ruptured, the peritoneal cavity was, of necessity, viewed
within 3 months for replacement of a blocked VP shunt,
and the peritoneum was noted to be clean. Reviewing the
literature suggests that the exteriorized shunt be placed
into another cavity in 2 weeks, and the previously infected
peritoneal cavity can be reused in 2 months. Fortunately,
there do not seem to be any serious long-term sequelae
for these children, although 4 (3 acute, 1 ruptured) had
their shunts revised between 3 months and 4 years. It
cannot be ascertained whether these subsequent postoper-
ative shunt infections were in any way related to the
previous appendicitis.
References
[1] Shandling B, Ein SH, Simpson JS, et al. Perforating appendicitis and
antibiotics. J Pediatr Surg 1974;9:79 - 83.
[2] Hoffman JH, Hendrick EB, Humphreys RP. Management of
hydrocephalus. Monogr Neural Sci 1982;8:21 - 5.
[3] Kulkarni HV, Drake JM, Lamberti-Pasculli M. CSF infection: a
prospective study of risk factors. J Neurosurg 2001;94:195 - 201.
[4] Walters BC, Hoffman HJ, Hendrick EB, et al. Cerebrospinal fluid
shunt infection. Influences on initial management and subsequent
outcome. J Neurosurg 1984;60:1014 - 21.
[5] Drake JM, Kestle JR, Millner R, et al. Randomized trial of CSF
shunt value design in pediatric hydrocephalus. Neurosurgery 1998;
43:294 - 303.
[6] Janik JS, Ein SH, Filler RM, et al. An assessment of the surgical
treatment of adhesive small bowel obstruction in infants and children.
J Pediatr Surg 1981;16:225 - 9.
[7] Leibrock L, Baker R, Uematsu S. Simulated acute appendicitis
secondary to ventriculo-peritoneal shunt. Surg Neurol 1976;5:105 - 7.
[8] Reynolds M, Sherman JO, McLone DG. Ventriculoperitoneal shunt
infection masquerading as an acute surgical abdomen. J Pediatr Surg
1983;18:951 - 4.
[9] Pumberger W, Lobl M, Geissler W. Appendicitis in children with a
ventriculo-peritoneal shunt. Pediatr Neurosurg 1998;28:21 - 6.
[10] Iannantuono B, Walton JM, Bass J, et al. The risk of ventriculo-
peritoneal shunt infection in patients with abdominal sepsis. Presented
at the meeting of the Canadian Association of Paediatric Surgeons,
Halifax, Canada, August, 1996.
[11] Rush DS, Walsh JW, Belin PR, et al. Ventricular sepsis and
abdominally related complications in children with cerebrospinal
fluid shunts. Surgery 1985;97:420 - 7.
[12] Hadani M, Findler G, Muggia-Sullam M, et al. Acute appendicitis in
children with a ventriculo-peritoneal shunt. Surg Neurol 1982;18:
69 - 71.
1258
[13] Krassoudakis A, Vlazakis S, Kakavelakis KN, et al. Ventriculoper-
itoneal shunting complicated with cerebrospinal fluid pseudocyst and
acute appendicitis. Minerva Pediatr 2002;54:321 - 3.
[14] Grosfeld JL, Cooney DR, Smith J, et al. Intra-abdominal complica-
tions following ventriculo-peritoneal shunt procedures. Pediatric
1974;54:791 - 6.
[15] Pittman T, Williams D, Weber TR, et al. The risk of abdominal
complications in children with ventriculo-peritoneal shunts. J Pediatr
Surg 1992;27:1051 - 3.
[16] Pople IK, Bayston R, Hayward RD. Infection of cerebrospinal fluid
shunts in infancy: a study of etiological factors. J Neurosurg
1992;77:29 - 36.
S.H. Ein et al.
[17] Dussaussois L, Rypens F, De Temmerman D, et al. Abdominal
complications of ventriculo-peritoneal shunts. J Radiol 1996;77:357 - 61.
[18] Agha FP, Amendola MA, Shirazi KK, et al. Abdominal complications
of ventriculo-peritoneal shunts with emphasis on the role of imaging
methods. Surg Gynecol Obstet 1983;156:473 - 8.
[19] Rekate HL, Yonas H, White RJ, et al. The acute abdomen in patients
with ventriculo-peritoneal shunts. Surg Neurol 1979;11:442 - 5.
[20] David IB, Buck JR, Filler RM. Rational use of antibiotics for
perforated appendicitis in childhood. J Pediatr Surg 1982;17:494 - 500.
[21] Kusano T, Miyazato H, Shimoji H, et al. Revision of ventriculo-
peritoneal shunt under laparoscopic guidance in patients with
hydrocephalus. Surg Laparosc Endosc 1998;8:474 - 6.