Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101246

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Interdisciplinary Neurosurgery: Advanced Techniques

and Case Management
journal homepage: www.elsevier.com/locate/inat

Review Article

Management of peritoneal abscess after ventriculoperitoneal shunt

Mahmoud M. Taha, Amr AlBakry *, Mahmoud Shamloul, Tarek Abdelbary
Department of Neurosurgery, Faculty of Medicine, Zagazig University, 44512, Egypt

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Ventriculoperitoneal shunt is an established and efficient treatment for hydrocephalus. Peritoneal
VP shunt abscess is a, rare, serious complication which should be managed aggressively. There is no general consensus for
Abscess managing peritoneal abscess after ventriculo-peritoneal (VP) shunt. Here we present our stepwise protocol of
Abdomen
management for a series of five cases.
Infection
Complications
Case presentations: We present a series of five cases diagnosed with peritoneal abscess after VP shunting. Patients
were fully investigated on admission. Abscess was confirmed by pelvic-abdominal U/S and diagnostic aspiration.
Conservative management was started with antibiotics according to culture and sensitivity initially in all cases.
Shunt externalization and apo-cath insertion was done for non-responsive cases. Further non-responsive cases
were managed by shunt removal and external ventricular drain (EVD) until subsidence of infection. The study
included 3 males and 2 female patients. One case responded to conservative measures, while the other four
needed more invasive procedures: apo-cath, shunt removal and EVD with intra-ventricular antibiotics.
Conclusion: Abdominal infection following VPS insertion is a serious complication associated with high morbidity
and mortality. Patients should be managed in collaboration with general surgery department staff. We propose a
management protocol that includes a systematic stepwise approach according to the general condition and
neurological status of each patient. The protocol starts with conservative treatment and progresses to more
invasive and aggressive methods according to the response of the patient.

1. Introduction This study provides a systematic stepwise approach for treating

Ventriculoperitoneal shunting (VPS) is an established and efficient
treatment for hydrocephalus [1]. Abdominal complications following
VPS are serious and associated with high morbidity and mortality [1–4].
These complications, include peritonitis, ascites, bowel and abdominal
wall perforation, inguinal hernias, and abscess formation [5]. The
prevalence of abdominal complications following VPS insertion ranges
from 5% to 47% [6,7]. Abdominal complications could occur early in
the form of bowel injury or perforation [8] or late occurring 30 days or
more from the onset, such as infection, loculated pseudocyst, visceral
perforation, and mechanical malfunction of the device [7]. In a study on
intra-abdominal complications after VPS, Chuang et al. have reported
that the incidence of peritoneal abscess was 5.7% [2].
Abdominal infections could be managed in different ways, including
conservative measures, laparoscopic exploration, and shunt revision,
removal, or reinsertion [1–5,9]. Here we report a series of five cases of
peritoneal abscess following VPS insertion and their management
protocols.
peritoneal abscess following VPS.
2. Methods
This study included five consecutive patients who were admitted to
our department from July 2018 to June 2019. The inclusion criteria
were patients with a history of VPS insertion presenting with abdominal
and/or neurological symptoms, pelvic–abdominal ultrasonography (U/
S) showing abdominal collection, and diagnostic aspirate revealing pus.
At our institution, we perform 70–95 VPS surgeries per year. During
the study period, our emergency department admitted 12 cases of shunt
failure (operated at our institution and/or other hospitals) due to vari­
able causes (eight shunt infection, two proximal obstructions, one over-
shunting, and one distal perforation).
Full history was obtained, and radiological assessments, including
pelvic–abdominal U/S and brain computed tomography (CT), were
performed.
Our treatment protocol, concurring with the perspective of the

* Corresponding author at: Neurosurgery Department, Faculty of Medicine, Zagazig University, Zagazig 44512, Egypt.
E-mail address: amrbakry@live.com (A. AlBakry).

https://doi.org/10.1016/j.inat.2021.101246
Received 8 January 2021; Received in revised form 20 April 2021; Accepted 1 May 2021
Available online 3 May 2021
2214-7519/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M.M. Taha et al.
general surgery department, started with conservative management and
antibiotic coverage (optimum, full dose according to culture and sensi­
tivity (C/S) for 14 days). Serial pelvic–abdominal U/S and complete
blood count were performed to evaluate management success. Nonre­
sponsive cases were managed by shunt externalization with Apo-Cath
insertion. Antibiotics were administered for 21 days. Patients who
showed persistent fever, abdominal tenderness and pain, abnormal CSF
chemistry and cytology, were considered non-responsive, and the shunt
is considered the source of infection. These cases had their shunts
removed, and an external ventricular drain (EVD) was inserted with or
without intraventricular antibiotics. After the infection subsided,
confirmed by three consecutive negative C/S and clear cerebrospinal
Fig. 1. Algorithm for treatment of peritoneal abscess.
2
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101246
fluid (CSF) chemistry, a new shunt was inserted, and the patients were
followed up for 12 months to ensure proper shunt functioning and no
recurrence of infection (Fig. 1).
3. Results
This series included five patients with ages ranging between 10
months and 18 years; only one patient was 50 years old. Among the five
patients, three were males, and two were females. The causes of hy­
drocephalus were congenital, postmeningitis, tumor, and subarachnoid
hemorrhage. The most common microorganism isolated from peritoneal
aspirate was Staphylococcus aureus, whereas the most common
M.M. Taha et al. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101246

microorganism isolated from CSF analysis was Escherichia coli. Only one
patient responded to the conservative treatment protocol, whereas the
other four required further intervention. A summary of all cases is shown
in Table 1.
3.1. Case 1
A-10-month-old male patient with postmeningitic hydrocephalus
and VPS. Three months later, the patient was admitted to the pediatric
unit due to fever, drowsiness, and abdominal rigidity.
Abdominal U/S showed abdominal collection, and sonar-guided
aspiration revealed frank thick pus. C/S revealed an abundance of
Staphylococcus aureus sensitive to tigecycline, a tetracycline, along with
Candida albicans growth in fungal culture. Antibiotic and antifungal
treatment for 2 weeks decreased the size of the abdominal collection.
The final CSF analysis was clear and normal. The patient had a chest
infection and could not be discharged; 5 days later, the patient had fever,
drowsiness, abdominal tenderness, and signs of toxemia. CSF analysis
was clear; abdominal U/S revealed adhesive peritonitis. The patient
underwent surgery to remove the shunt; abdominal exploration was
performed for the removal and lysis of adhesions; and peritoneal lavage
was performed. The patient remained at our department for 2 weeks to
ensure that infection completely subsided, and a new ventriculoatrial
shunt was inserted. At 6- and 12-month follow-up, the patient was
healthy and in good general condition with a properly functioning shunt
and had no signs of infection or abdominal recurrence.
3.2. Case 2
A 7-year-old male patient had congenital hydrocephalus and oper­
ated for a left occipital VPS at the age of 2 months. At 6 months of age,
the patient required another right-sided shunt due to insufficient CSF
shunting. Right shunt replacement was performed at five years of age
due to nonfunctioning shunt. Seven months later, the patient was
admitted to the emergency department due to headache and drowsiness.
Physical examination revealed no abdominal signs, and stony hard left
reservoir was observed.
Abdominal U/S showed a rim of free fluid around the right shunt
with a left lumbar collection (6 × 10 cm) around the tip of the other
shunt, which was confirmed by CT (Fig. 2). We did a diagnostic aspi­
ration of pus and administered tigecycline for 2 weeks according to C/S.
The shunt started functioning again, and follow-up U/S was clear. A CSF
sample was taken for analysis and C/S. Escherichia coli sensitive to
gentamycin was the offending microorganism. The patient received
antibiotics for 2 weeks until complete subsiding of the infection and was
discharged in a good health state for follow-up. Follow-up at 6 and 12
months showed a well-functioning shunt and good general condition
without abdominal or neurological signs.
3.3. Case 3
A 6-year-old female patient with hydrocephalus and myelome­
ningocele operated at the age of 3 months. The patient was admitted to
the general surgery department for acute abdomen. Pelvic–abdominal
U/S showed intraperitoneal collection; aspirational C/S revealed the

Table 1
Summary of 5 cases: including Age, Sex, Presentation, Radiological and laboratory findings, management and follow-up.
No. 1 2 3 4 5

Age (yrs.) 10 m 7 6 18 50
Sex M M F M F
Cause of Post meningetic hydrocephalus Congenital Congenital Medulloblastoma Spontaneous SAH
Hydrocephalus Hydrocephalus Hydrocephalus with
myelomeningocele
Neurological Fever, drowsiness Headache, drowsiness, None Fever, Drowsiness Fever, Drowsiness
Findings stony hard reservoir
Abdominal Vomiting, abdominal rigidity None Acute abdomen Slight abdominal tenderness Abdominal tenderness,
Findings rigidity
Source of Spontaneous bacterial peritonitis Left shunt infection CSF Infection CSF infection Periapendicular abscess
Peritonitis
Radiology Abdominal U/S: abdominal Left lumbar collection Intraperitoneal Intraabdominal collection 1st PUAS: Intraabdominal
collection, aspiration: turbid 6X10 cm. collection around the tip of the collection and LT lumbar
exudative fluid Serial U/S showed peritoneal end of the tube collection 4.5 X 3 cm
decrease in size of the Serial PUAS showed decrease
collection until in size of collection until
disappeared final one showed complete
resolution of the collection.
Late CT Abdomen and Pelvis:
No collection
CSF culture & Escherichia Coli Escherichia Coli Pseudomonas: Acinetobacter baumannii: Escherichia Coli: Amikin,
sensitivity gentamycin, Amikin Colistin Gentamycin Acinetobacter
baumannii: Colistin
Peritoneal Staphylococcus aureus: Staphylococcus aureus: Acinetobacter Staphylococcus aureus Klebsiella; Vancomycin &
Aspirate culture Tigacycline Tigacycline baumannii: Colistin Meronem
& sensitivity Antifungal
Optional Antibiotics only without shunt U/S aspiration of abscess Shunt externalization Apo-Cath which drained Shunt removal and EVD
treatment removal → recurrence of then shunt removal and pure pus, Shunt removal and insertion– U/S guided Apo
symptoms. Then removal of shunt EVD EVD insertion catheter for peritoneal
dialysis
Antibiotic Antibiotic and antifungal IV Tigacycline for 14 Intraventricular and IV IV Colistin for 22 days IV antibiotic was given
Regimen according to culture. days gentamycin for 14 days, according to the culture,
Colistin by IV Intraventricular gentamycin
was given for 10 days
Follow-up The general condition improved Follow-up at 6 and 12 New VPS after removal After CSF became clear and Abdominal abscess
after removal of the shunt, with months show good of the EVD CT abdomin-pelvis was free disappeared; CSF is clear;
disappearance of all abdominal functioning valve with EVD was removed, and a new Ventriculo-jugular
signs and symptoms, a ventriculo- no signs of infection new VPS was inserted. shunt was inserted.
atrial shunt was inserted.

3
M.M. Taha et al.
Fig. 2. Abdominal CT scan of 7-year-old patient showing peritoneal abscess
around the tip of the peritoneal end.
growth of Acinetobacter baumannii, sensitive to colistin. Neurosurgery
consultation was requested, and we decided to administer an antibiotic
for 2 weeks and follow-up with serial U/S, which showed no response to
the treatment, and we decided to externalize the shunt, and an Apo-Cath
was inserted. The abdominal collection and signs disappeared on serial
abdominal U/S. CSF analysis and C/S gave growth to Pseudomonas
aeruginosa sensitive to gentamycin and amikacin. The shunt was
removed, and an EVD was inserted; C/S of the CSF from the EVD gave
growth to Pseudomonas, sensitive to gentamycin, which was intrave­
nously administered for 14 days. The infection did not subside, and thus,
intraventricular antibiotics were administered for another 14 days.
Follow-up CSF analysis was normal, and Erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP) were in normal ranges. The EVD was
removed, and a VPS was inserted, and the patient was discharged for
follow-up. We performed our routine follow-up at 6 and 12 months, and
the shunt was well-functioning without any signs of malfunction or
infection.
3.4. Case 4
An 18-year-old male patient had a VPS for treating hydrocephalus
due to a medulloblastoma. Nine months later, the patient presented with
fever, drowsiness, abdominal pain, and tenderness and was admitted to
the general surgery department. He had an Apo-Cath inserted, which
drained pure pus. CSF analysis from the valve revealed Acinetobacter
baumannii sensitive to colistin. C/S from the Apo-Cath revealed no
growth. The shunt was externalized, and the patient received antibiotics
according to C/S. The abdominal collection decreased on serial U/S.
Then, the shunt was removed, and an EVD was inserted. Antibiotics
were intravenously administered for 21 days according to C/S. ESR and
CRP levels were in normal ranges, and the final CSF analysis was clear of
abnormalities. The EVD was removed, and a new VPS was inserted on
the other side. The patient was discharged for follow-up. At 6- and 12-
month follow-up, the shunt was well-functioning, and the patient’s
general condition was good.
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Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101246
3.5. Case 5
A 50-year-old woman diagnosed with post subarachnoid hemor­
rhage hydrocephalus underwent VPS. One week later, the patient un­
derwent a revision of the peritoneal end due to subcutaneous positioning
of the shunt. The patient was discharged and was readmitted to the
emergency department 4 months later, due to fever, abdominal pain,
and drowsiness. Physical examination revealed abdominal tenderness
and rigidity. Brain CT revealed hydrocephalic changes with dilatation of
both temporal horns (Fig. 3), and pelvic–abdominal U/S showed left
lumbar collection around the tip of the shunt measuring 4.5 × 3 cm,
confirmed by pelvic and abdominal CT (Fig. 4).
U/S-guided aspiration of the collection was performed, which
revealed pure pus, which was sent for C/S, along with CSF sampling
from the reservoir for analysis and C/S. Klebsiella pneumoniae sensitive to
vancomycin was observed from the abdominal sample, and growth from
CSF harbored Escherichia coli sensitive to amikacin. Antibiotics were
administered for 2 weeks with serial U/S follow-up, which revealed
recollection around the peritoneal tip.
Thus, shunt externalization was performed with Apo-Cath drainage
of the abscess. New C/S showed growth of Klebsiella pneumoniae sensi­
tive to vancomycin and meropenem, and CSF analysis revealed Escher­
ichia coli bacterial growth sensitive to amikacin and gentamycin.
Antibiotics were administered according to C/S for 3 weeks. The
abdominal collection disappeared (Fig. 5), but CSF analysis remained
positive. Then, the shunt was removed, and we inserted a closed EVD
system. CSF C/S from the EVD showed a growth of Staphylococcus aureus
sensitive to cefepime and gentamycin. Cefepime was intravenously
administered at a dose of 2 g/8h, while gentamycin was intraventricu­
larly administered at a dose of 10 mg/12 h. Both antibiotics were
administered for 10 days. ESR and CRP returned to their normal values,
the CSF became clear with normal analysis (cells = 10/dL; protein = 40
mg/dL; glucose = 79 mg/dL), and a new ventriculojugular shunt was
inserted, and the patient was discharged for follow-up. The patient was
doing well at the 6- and 12-month follow-up
4. Discussion
This study included five consecutive patients with peritoneal abscess
following VPS insertion. The patients’ age ranged from 10 months to 50
years. Among them, three were males and two were females. All patients
presented with abdominal manifestations with general constitutional
manifestations and/or neurological manifestations due to shunt mal­
function. Our management protocol, after confirming diagnosis using
pelvic–abdominal U/S, diagnostic aspiration, pelvic and abdominal CT,
and brain CT to exclude any neurosurgical emergency, was conservative
management using antibiotics according to C/S, with clinical and serial
U/S follow-up for evaluating symptoms and confirming decreases in the
size of the abscess. After 2 weeks of no response or with recurrence of the
abscess after drainage, we moved to the next step: Apo-Cath drainage
and externalization of the shunt through the chest wall. Prolonged cases
or persistence of the CSF infection more than 21 days were treated by
removing the shunt, applying an EVD system, and administering IV
antibiotics for 14 days. Intraventricular antibiotics according to C/S
were administered only if CSF infection persisted after the previous
steps. After infection subsidence confirmed using CSF analysis (three
consecutive clear cultures and normal analysis) and pelvic–abdominal
CT, a new shunt was inserted using either the ventriculoatrial or ven­
triculoperitoneal route or a VPS on the contralateral side.
The patients were followed up for up to 12 months, with repeated
monitoring of any signs of infection, recurrence of abdominal collection
or abscess, and shunt function.
Abdominal pseudocysts were first described by Harsh in 1954 [10].
The most common cause of abdominal CSF pseudocyst is infection. This
theory may help describe the pathology of abdominal abscess formation.
The abdomen responds to infection by sheathing off the peritoneal
M.M. Taha et al.
Fig. 3. Brain CT scan showing hydrocephalic changes and dilatation of the temporal horns.
Fig. 4. Abdominal CT scan of 50-year-old patient showing LT lumbar peritoneal abscess.
catheter. CSF draining continuously into the sheath may lead to large
abdominal fluid-filled cysts. The infection, high protein content in the
CSF, and reaction to the tube all lead to decreased absorption of the CSF.
The time from shunt placement to cyst formation ranges from 3 weeks to
5 years [1,2,11,12]. In this study, the patients developed peritoneal
abscess after a period that ranged from 3 months to 6 years after shunt
infection.
In many studies, abdominal infection following VPS has been treated
using different protocols [1–19]. In this study, we started with conser­
vative management and proceeded to more aggressive treatment stra­
tegies according to the response of each individual case.
Abdominal symptoms and signs were the main presenting manifes­
tations—the patients had abdominal pain, tenderness, and rigidity and
vomiting and were admitted to the general surgery department. One
patient did not show any abdominal manifestations but presented with
manifestations of shunt obstruction and increased intracranial pressure.
The presence of abdominal symptoms in the absence of neurological
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Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101246
symptoms or signs of shunt malfunction [1,2,9,13] should raise the
suspicion of the abdominal complications of VPS in patients who had
previous VPS surgery and showed acute abdominal manifestations,
which may be difficult to differentiate from appendicitis by clinical
means only [14].
We started our management protocol by performing pel­
vic–abdominal U/S and abdominal CT to investigate the cause of acute
abdomen, both of which revealed an abdominal collection around the
tip of the peritoneal end of the shunt. A follow-up brain CT was per­
formed to rule out any central nervous system complications. Diagnostic
aspiration of the fluid using a fine needle under U/S guidance was
performed to analyze the fluid and to obtain samples for C/S to start
with the antibiotic regimen. In addition, we performed CSF sampling
from the reservoir for analysis, C/S, and exclusion of CSF infection. ESR
and CRP levels were assessed to have a baseline for the evaluation of the
progress of the treatment.
Staphylococcus aureus was the most common isolated microorganism
M.M. Taha et al.
Fig. 5. Abdominal CT scan of 50-year-old patient showing resolution of the abscess.
from the abdomen (3/5 cases), whereas in the other two cases, Klebsiella
pneumoniae and Acinetobacter baumannii were the most common isolated
microorganisms. In three patients, Escherichia coli was the most common
isolated bacteria from the CSF, whereas in the other two cases, Pseudo­
monas aeruginosa and Acinetobacter baumannii were the most common.
Only one case had concomitant fungal infection and received an anti­
fungal agent for 14 days. Fungal infection in the context of VPS has been
reported, either as primary infection or secondary to bacterial infection
[16,20–22]. The patients received antibiotics—common antibiotics
from both abdominal and CSF cultures or a combination of antibiotics if
different sensitivities were present, for 14 days with serial U/S follow-up
to check for recollection, and at the follow-up, ESR and CRP were
measured to evaluate the patients’ antibiotic response and infection
subsidence. The conservative management protocol was adopted by
some authors [2,3,23] and was successful in treating infection without
any surgical intervention.
Only one patient responded to the conservative management pro­
tocol, whereas the other four patients were nonresponsive. Thus, we
shifted to the second tier of treatment, which involved Apo-Cath
drainage of the abscess with externalization of the shunt through the
chest wall. All these procedures were performed with continuous anti­
biotic cover for 21 days. Serial abdominal U/S and abdominal CT
showed the disappearance of the abdominal collection. In addition,
clinical signs of abdominal infection started to disappear. Shunt exter­
nalization and Apo-Cath drainage have been performed by many neu­
rosurgeons as the first line of treatment or as a second-line treatment
after failure of the conservative method [1,5,13,14,23].
6
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 25 (2021) 101246
This protocol acts as a finding-based algorithm for managing peri­
toneal abscess following VPS insertion. This knowledge raises the sus­
picion of neurosurgeons dealing with cases presenting with shunt failure
to a serious complication.
Our study was limited by the few number of cases, and heterogenous
causes of hydrocephalus, however it presents a systematic stepwise
approach for treatment of peritoneal abscess after VPS. A large popu­
lation study is recommended to add more information to the protocol.
5. Conclusion and recommendations
Abdominal infection following VPS insertion is a serious complica­
tion associated with high morbidity and mortality. Patients should be
managed in collaboration with general surgery department staff. We
propose a management protocol that includes a systematic stepwise
approach according to the general condition and neurological status of
each patient. The protocol starts with conservative treatment and pro­
gresses to more invasive and aggressive methods according to the
response of the patient.
6. Statement of Ethics
This study has included no human trials; all patients were managed
according to standards of management. All patients gave written con­
sents for treatment according to our standard protocols. No identifying
information is present in the case presentations or in the images. All
consents have been taken to include in the study. All patients or their
M.M. Taha et al.
guardians have given their written consent for publication of data and
images.
Funding sources
None.
Author contributions
Dr Mahmoud M. Taha: Study Supervision and management de­
cisions, Data revision, Final approval.
Dr Amr AlBakry: Management decisions, protocol adherence, pre­
paring manuscript, Final approval, study submission.
Dr Mahmoud Shamloul: Data Gathering.
Dr Tarek Abdelbary: Final approval and study overlooking.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgement
The study has been performed at Neurosurgery Department, Faculty
of Medicine. Zagazig University with no contributions from any in­
dividuals or organizations apart from the authors. No special equipment
or devices were used in the study.
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