Chapter 20
Umbilical Disorders
Spencer W. Beasley
Key Points
››Umbilical hernias are common in small children, occurring in about 10% of infants after separation of the umbilical cord, but the vast majority of them involute spontaneously.
››Umbilical hernias virtually never ulcerate, rupture, strangulate or give pain.
››Umbilical hernias only need to be repaired if they are still present beyond the age of 3–4 years: this is done as a day case under a short general anesthetic.
››A moist lump at the umbilicus is usually an umbilical granuloma or ectopic bowel mucosa, and can be treated with topical application of silver nitrate.
››Discharge of air, or ileal content in the presence of a small opening suggests a vitellointestinal tract; and discharge of urine from an opening at the umbilicus indicates a urachus.
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20.1 Introduction
The umbilicus can be the site of a variety of abnormalities, most of which are minor. The most common is the umbilical hernia, and about 90% of these involute spontaneously, usually in the first few years of life. In contrast to inguinal hernias, strangulation of an umbilical hernia is extremely uncommon.
20.2 Common Umbilical Conditions
1.Umbilical hernia: Umbilical hernia presents as a skin-cov- ered swelling at the umbilicus, first seen after separation of the cord (Fig. 20.1). It increases in size with increasing abdominal pressure, (e.g., with crying, straining) but reduces when the infant is relaxed.
2.Umbilical granuloma: this appears as a fleshy pink protuberance which is moist, causing yellow staining of the overlying clothing. It becomes apparent after separation of the umbilical cord, and has no sinus opening (Fig. 20.2a).
3.Ectopic bowel mucosa at the umbilicus: this has an appearance similar to an umbilical granuloma but tends to be more “cherry red” and may bleed more readily.
FIGURE 20.1. Typical appearance of an umbilical hernia.
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a
b
FIGURE 20.2. (a) An umbilical granuloma presents as a moist and fleshy protuberance at the umbilicus that has no sinus opening. (b) An umbilical granuloma often has a “stalk.” Here it is being held up by forceps.
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4.Patent urachus: there is an opening at the umbilicus through which urine passes (because there is a connection with the bladder). A urachal remnant may also present as a blind ending sinus or as a urachal abscess inferior to the umbilicus.
5.Patent vitellointestinal tract: there is an open communication between the ileum and the umbilicus. Gas and fluid ileal contents can pass through it, appearing from a small opening on the umbilicus (Fig. 20.3). There are a number of variants of this condition including a sinus, Meckel’s diverticulum and Meckel’s band.
6.Exomphalos (or omphalocele): the umbilicus is widely open, and bowel and liver protrude through the broad umbilical cicatrix, but are contained by a sac consisting of peritoneum and an amniotic layer. Often the infant has associated abnormalities such as cardiac and renal defects, or Beckwith-Wiedemann Syndrome.
7.Gastrochisis: there is a relatively small defect immediately to the right of the umbilicus through which bowel protrudes antenatally, without any evidence of a sac (thus distinguishing it from exomphalos). The bowel is often
FIGURE 20.3. A patent vitello-intestinal tract has an opening through which fluid ileal contents and air can leak.
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edematous and thickened, and there may be an associated bowel atresia.
8.Omphalitis: this is a neonatal infection emanating from the umbilicus, causing streaks of erythema radiating from the umbilicus.
20.3 Treatment of Conditions
of the Umbilicus
1.Umbilical hernia: Those that do not resovle spontaneously are repaired after 3 years of age as a day case under a short general anesthetic. The scar is within the umbilicus, and recurrence is unlikely.
2.An umbilical granuloma and ectopic bowel mucosa are treated either with topical application of silver nitrate to the base of the stalk, or by ligation of the (often narrow) base with a suture tied tightly. Care should be taken to ensure that there is no sinus opening, as this may indicate an underlying vitellointestinal tract or urachus.
3.Where a patent urachus is suspected, imaging with a sinugram or ultrasonography may reveal the extent of the abnormality. Treatment involves surgical excision.
4.Vitellointestinal tract: this also can be confirmed by a sinugram. Once confirmed, treatment is by surgical excision of the tract.
5.Exomphalos (or omphalocele): this is often first diagnosed on antenatal ultrasonography. Its characteristic appearance makes it easily diagnosed at birth.Associated abnormalities (e.g., renal, cardiac, and chromosomal) should be excluded. Emergency management involves prevention of excessive heat loss (wrap the torso including the defect in plastic film and place the infant in a warm humidicrib), insertion of an intravenous line, and nasogastric decompression. These children are then treated in a neonatal unit. Surgery returns the bowel contents to the peritoneal cavity and the defect is closed. For extremely large defects, preliminary non-surgi- cal treatment by external compression may be required.