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Archives de pédiatrie
Volume 21, n° 8
pages 869-872 (août 2014)
Doi : 10.1016/j.arcped.2014.05.019
Received : 6 October 2013 ;  accepted : 12 May 2014
Récurrence d’un kyste abdominal de liquide céphalo-rachidien chez un adolescent de 14ans porteur d’un drain ventriculo-péritonéal
Abdominal CSF pseudocyst recurrence in a 14-year-old patient with ventricular-peritoneal shunt
 

P. Laurent a, , J.-L. Hennecker b, A. Schillaci c, V. Scordidis d
a Université catholique de Louvain, Louvain, Belgique 
b Service de pédiatrie, clinique Notre-Dame de Grâce, chaussée de Nivelles, 212, 6041 Gosselies, Belgique 
c Service de chirurgie viscérale, clinique Notre-Dame de Grâce, Gosselies, Belgique 
d Service de neurochirurgie, clinique Notre-Dame de Grâce, Gosselies, Belgique 

Auteur correspondant.
Résumé

La survenue d’un kyste abdominal de liquide céphalo-rachidien (LCR) chez les sujets porteurs d’un drain ventriculo-péritonéal (DVP) est une complication rare dont l’origine reste discutée. Toutefois, il s’agit d’un diagnostic à évoquer chez tout enfant présentant des plaintes abdominales ou des signes de dysfonction du drain. Nous rapportons le cas d’un adolescent âgé de 14ans qui présentait des symptômes d’hypertension intracrânienne (HTIC). Il était porteur d’un DVP depuis ses premiers mois pour une hémorragie intraventriculaire et avait déjà présenté un kyste abdominal de LCR 3 mois auparavant. Le diagnostic de récidive du kyste a été posé par l’échographie abdominale et le traitement a consisté en une résection partielle du kyste par laparotomie avec repositionnement du drain. Aucune antibiothérapie n’a été instaurée. L’échographie est la méthode diagnostique de choix pour mettre en évidence de tels kystes. Beaucoup de traitements ont été proposés mais il est difficile de prévenir la fréquence élevée des récidives. En cas de récurrence, la possibilité d’une infection sans signe direct est à considérer, susceptible de justifier une antibiothérapie, de même que la possibilité d’un déficit de résorption du péritoine. Le traitement proposé est soit l’ablation du DVP avec mise en place d’un drainage ventriculaire externe en cas d’infection avérée, soit l’externalisation de la partie distale du DVP en l’absence de signes infectieux directs. Le repositionnement d’un drain est effectué dans un second temps.

The full text of this article is available in PDF format.
Summary

Abdominal cerebrospinal fluid (CSF) pseudocyst is a rare complication of ventricular-peritoneal shunt (VPS) but needs to be considered in every patient with abdominal complaints or signs of intracranial hypertension (IH). The pathogenesis of pseudocysts remains unclear. Diverse predisposing factors have been proposed such as previous abdominal surgeries, multiple VPS revisions, infections, history of necrotizing enterocolitis, and nonspecific inflammatory processes. We report the case of a 14-year-old patient, known to have a VPS as intraventricular hemorrhage treatment, presenting cephalalgia, vomiting, apathy, and an indurate abdominal mass without fever. The first abdominal CSF pseudocyst diagnosis had been established 3months earlier. Abdominal ultrasounds confirmed a large homogeneous cyst with the shunt tip within the pseudocyst. Cerebral CT revealed an increased ventricular size. An exploratory laparotomy with cyst aspiration, lysis of adhesions, excision of cystic walls, and repositioning of the peritoneal catheter was performed. No antibiotics were initiated given that the cultures were negative. Ultrasonography proved to be the method of choice in the diagnosis of VPS abdominal complications, especially CSF pseudocyst. CT can also reliably confirm the pseudocyst. In case of IH signs, a cerebral CT scan can be performed to evaluate the ventricular distension and to check the shunt position. Various methods to process the cyst have been described in the medical literature, but the recurrence rate remains elevated (25–100%). Then the probability of an infection without any clinical sign has to be considered. In case of suspected infection, the VPS is removed and replaced by an external ventricular drain. Antibiotics are started and adjusted to the results of the CSF culture. If there is no direct sign of infection, only the distal catheter is externalized and antibiotics are introduced until infection is treated. Depending on the peritoneal absorption state, the distal catheter is replaced in the abdominal cavity or in the atrium, the pleural space or the gallbladder if there is no suitable place for repositioning. If the peritoneal state allows it, a laparoscopic procedure is recommended to avoid peritoneal adhesion formation increasing the recurrence rate of CSF pseudocyst.

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