Umbilical Pathology

Question 1

What are some common pathologies associated with the umbilicus?

Answer 1

Umbilical pathologies include abdominal wall defects (e.g., gastroschisis and exomphalos), umbilical hernias, discharges from the vitelline duct (omphalomesenteric/vitello-intestinal duct) or urachus, granulomas, and sepsis.

Question 2

What is the cause of stool discharge from the umbilicus?

Answer 2

Stool discharge from the umbilicus is caused by a patent vitello-intestinal duct.

Question 3

What is the cause of urine discharge from the umbilicus?

Answer 3

Urine discharge from the umbilicus is caused by a patent urachus.

Question 4

What conditions can cause purulent discharge from the umbilicus?

Answer 4

Purulent discharge can result from an umbilical granuloma, omphalitis, or a tuberculosis (TB) fistula.

Question 5

What conditions can cause bloody discharge from the umbilicus?

Answer 5

Bloody discharge can be due to cord trauma or an umbilical granuloma.

Question 6

When does the opening between the mid-portion of the digestive tube and the yolk sac appear, and when is it usually obliterated?

Answer 6

The opening appears during the 4th week of gestation and is typically obliterated by the 7th to 9th week.

Question 7

What is the function of the yolk sac during early embryonic development?

Answer 7

The yolk sac (umbilical vesicle) provides nutrition to the early embryo via the vitelline artery.

Question 8

What can happen if remnants of the vitello-intestinal duct persist?

Answer 8

Persistent remnants can lead to a spectrum of congenital malformations.

Question 9

How common are persistent remnants of the vitelline duct in the population?

Answer 9

They occur in 0.2 to 4% of the population.

Question 10

How common is a patent vitelline duct among live births?

Answer 10

A patent vitelline duct occurs in fewer than 1 in 5000 live births.

Question 11

What is the most common anatomical variant of vitelline duct remnants?

Answer 11

Meckel’s diverticulum.

Question 12

What is the most common presentation of Meckel’s diverticulum in children?

Answer 12

Bleeding from ectopic gastric mucosa, causing mucosal ulceration at the base of the diverticulum.

Question 13

How does Meckel’s diverticulum commonly cause bowel obstruction?

Answer 13

Through small bowel intussusception, which is the presenting problem in about 20% of symptomatic patients, typically at around 2 years of age.

Question 14

How does diverticulitis from Meckel’s diverticulum typically present?

Answer 14

Abdominal pain due to diverticulitis is rare and may progress to perforation. It is often diagnosed during surgery for suspected appendicitis.

Question 15

What imaging technique is used to detect ectopic gastric or bleeding mucosa in Meckel’s diverticulum?

Answer 15

Nuclear scintigraphy (Meckel scan) or red cell scan is useful, especially when endoscopy is negative.

Question 16

When is diagnostic laparotomy considered in Meckel’s diverticulum?

Answer 16

It may be performed if bleeding persists despite a negative Meckel scan.

Question 17

What is the recommended surgical management for asymptomatic incidentally discovered Meckel’s diverticulum?

Answer 17

Surgical excision is recommended unless the base is very wide and the lesion is short, with no visible or palpable ectopic mucosa.

Question 18

When might resection and anastomosis be necessary in Meckel’s diverticulum?

Answer 18

If there is significant ulceration at the mesenteric aspect of the diverticulum.

Question 19

How does a vitelline fistula typically present?

Answer 19

As a sinus draining dark fluid or stool from the umbilicus.

Question 20

What imaging technique is useful to confirm the diagnosis of a vitelline fistula?

Answer 20

A fistulogram is useful before surgical exploration and resection.

Question 21

What is the role of a fibrous band and persistent vitelline artery in the context of Meckel’s diverticulum?

Answer 21

A fibrous band, often associated with 25% of Meckel’s diverticula, can tether the bowel to the umbilicus, sometimes presenting even without the presence of a Meckel’s diverticulum.

Question 22

What is the risk associated with the fibrous band connecting the bowel to the umbilicus?

Answer 22

The fibrous band poses a risk for volvulus around the band, leading to signs of bowel obstruction.

Question 23

How is bowel obstruction caused by a fibrous band managed?

Answer 23

Management includes NGT drainage, NPO (nil by mouth), IV fluid resuscitation, and antibiotics.

Question 24

What is the surgical approach if bowel necrosis occurs due to a persistent fibrous band?

Answer 24

Surgical exploration and division of the fibrous band, with bowel resection if complicated by necrosis.

Question 25

How does an umbilical sinus typically present?

Answer 25

It presents with mucous drainage from a small defect at the umbilicus.

Question 26

What diagnostic technique is useful to exclude a fistula before surgical exploration in the case of an umbilical sinus?

Answer 26

A contrast study is useful to exclude a fistula before surgical exploration and resection.

Question 27

What are the likely presenting symptoms of an umbilical cyst?

Answer 27

Bowel obstruction (especially if within a persistent fibrous band with volvulus) or sepsis (infection with purulent contents).

Question 28

Can an umbilical cyst be palpated?

Answer 28

Yes, a mass may be palpable if the cyst is superficial

Question 29

What is the differential diagnosis of a cystic lesion at the umbilicus?

Answer 29

The differential diagnosis includes a urachal cyst (more superficial, no bowel communication but may become infected) and a duplication cyst

Question 30

What are the diagnostic methods used to establish the diagnosis of an umbilical cyst?

Answer 30

Ultrasound or exploratory laparotomy usually establishes the diagnosis.

Question 31

What is the treatment for an umbilical cyst?

Answer 31

Surgical excision is required.

Question 32

How does an umbilical polyp typically present?

Answer 32

As a glistening “red cherry” at the umbilicus from birth, caused by persistent gastrointestinal mucosa.

Answer 33

A pyogenic granuloma, which appears a few weeks after birth and can be treated with topical table salt or silver nitrate stick application.

Question 34

How is a true umbilical polyp treated?

Answer 34

It requires umbilical exploration under general anesthesia with resection of the ectopic mucosa.

Question 35

Where can luminal narrowing in the midgut occur?

Answer 35

It may occur at the previous site of the vitelline duct.

Question 36

How does luminal narrowing in the midgut typically present?

Answer 36

It is rarely symptomatic but may present with bowel obstruction.

Question 37

What is the management for luminal narrowing in the midgut causing bowel obstruction?

Answer 37

Surgical exploration is required if bowel obstruction occurs.

Question 38

What is the prevalence of Meckel’s diverticulum in the population?

Answer 38

Meckel’s diverticulum occurs in 2% of the population, with an incidence range of 0.2 to 4%.

Question 39

What percentage of individuals with Meckel’s diverticulum are symptomatic?

Answer 39

It is symptomatic in 2% of cases, though complications occur in approximately 5%.

Question 40

How does Meckel’s diverticulum present in terms of gender?

Answer 40

It is twice as common in males compared to females.

Question 41

At what age does Meckel’s diverticulum usually present?

Answer 41

It typically presents before 2 years of age.

Question 42

Where is Meckel’s diverticulum usually located in the small bowel?

Answer 42

It is usually located within 2 feet (50 cm) of the ileocecal valve on the antimesenteric aspect of the small bowel.

Question 43

What is the typical length of Meckel’s diverticulum?

Answer 43

Meckel’s diverticulum is usually about 2 inches (5 cm) long.

Question 44

What types of ectopic mucosa are typically found in Meckel’s diverticulum?

Answer 44

It may contain up to two types of ectopic mucosa, usually gastric (in 2/3 of cases) and occasionally pancreatic (2 to 6%).

Question 45

How does an umbilical granuloma typically form?

Answer 45

It may occur when the umbilical cord falls off, leaving some exposed mucosa.

Question 46

What is the treatment for an umbilical granuloma?

Answer 46

Treatment options include silver nitrate application or, if persistent, tying the granuloma at the base.

Question 47

How can an umbilical granuloma be differentiated from a true umbilical polyp?

Answer 47

An umbilical granuloma has a more irregular, less mucoid surface and arises after the umbilical cord falls off, while a true umbilical polyp presents from birth with a glistening, cherry-like appearance.

Question 48

What is omphalitis?

Answer 48

Omphalitis is a serious infective condition that can progress rapidly to severe sepsis and death, typically occurring in newborns and young babies.

Question 49

How can omphalitis be prevented?

Answer 49

Umbilical cord care with daily surgical spirits (>90% alcohol) application until the cord is dried, while protecting the surrounding skin from alcohol, helps prevent omphalitis.

Question 50

What is the treatment for omphalitis?

Answer 50

Broad-spectrum antibiotics are used, with Staphylococcus aureus being the most common cause. Saline, hydrogel, or silver-based dressings may be sufficient if no surrounding cellulitis is present.

Question 51

How should cellulitis surrounding the umbilicus be managed in cases of omphalitis?

Answer 51

If cellulitis is present, the baby should be monitored in the hospital. If there is any edema of the surrounding skin, urgent aggressive debridement under general anesthesia is required.

Question 52

Why is necrotizing fasciitis a concern in omphalitis, and how should it be managed?

Answer 52

Necrotizing fasciitis can progress very rapidly in neonates with a mortality rate >50%. Repeat assessments are necessary to monitor for this condition, as it can spread rapidly and lead to death within 24-48 hours if not treated with surgery in time.

Question 53

When does a tuberculous fistula typically occur, and how does it present?

Answer 53

It can occur in older patients, following an abscess that spontaneously drains, and may be associated with an enterocutaneous fistula.

Question 54

How is tuberculous fistula diagnosed?

Answer 54

The diagnosis is confirmed through clinical evaluation and appropriate investigations, such as imaging and culture, to detect Mycobacterium tuberculosis.

Question 55

What is the management approach for a tuberculous fistula?

Answer 55

Conservative management with tuberculosis drugs may lead to resolution, provided there is no distal bowel obstruction from tuberculous adhesions or strictures.

Question 56

What is patent urachus, and how does it present?

Answer 56

Patent urachus is a fistula between the bladder and the umbilicus that drains urine. It is rare, occurring in about 1 in 10,000 babies.

Question 57

What is the embryological origin of the urachus, and how does it develop?

Answer 57

The urachus is a fistula between the apex of the bladder and the umbilicus. It usually narrows cranially and atrophies to a fibrous cord before birth, as the bladder descends away from the umbilicus.

Question 58

How is patent urachus diagnosed?

Answer 58

Raised fluid urea/creatinine in leaking fluid from an umbilical fistula indicates patent urachus. Imaging (kidney/ureter/bladder ultrasound, ±MCUG/fistulogram) is used to rule out underlying bladder outlet obstruction.

Question 59

What is the management approach for patent urachus?

Answer 59

The condition is managed with surgical closure after ruling out underlying bladder outlet obstruction, such as posterior urethral valves or neurogenic bladder.

Question 60

What is cord trauma, and how is it commonly presented in neonates?

Answer 60

Cord trauma refers to minor bleeding after dehiscence of the cord stump, which usually occurs within 1-2 weeks after birth. It may indicate infection or slight trauma.

Question 61

How should cord trauma be evaluated in neonates?

Answer 61

Carefully evaluate for any necrotic tissue that may require debridement, or for signs of ectopic mucosa from an umbilical polyp.

Question 62

How can early formation of an umbilical granuloma be treated?

Answer 62

Topical table salt can help prevent and treat early formation of an umbilical granuloma.

Question 63

What is an umbilical hernia, and where is it located?

Answer 63

An umbilical hernia is a small residual sheath defect at the insertion of the umbilical cord.

Question 64

How does an umbilical hernia evolve over time?

Answer 64

The hernia narrows down over time in most people due to contractile fibers around the defect within the sheath edges.

Question 65

What is the risk of incarceration in an umbilical hernia, and what may become incarcerated?

Answer 65

The risk of incarceration of bowel is very low, but rarely omentum can become incarcerated, causing pain and an irreducible swelling.

Question 66

What are the risk factors for umbilical hernias and complications?

Answer 66

Umbilical hernias are more common in those of African descent, and spontaneous closure usually occurs before 5 years of age. Risk factors for complications include pica (eating non-food items like sand), which increases the risk of bowel incarceration and obstruction.

Question 67

When is urgent surgical repair required for an umbilical hernia?

Answer 67

Urgent surgical repair is required for acute presentations with incarceration.

Question 68

What rule can be used to determine which non-complicated umbilical hernias will close spontaneously?

Answer 68

The “<2cm at 2 years” rule suggests that if the defect is less than 2 cm at 2 years of age, the hernia is likely to close spontaneously and not require surgical closure.

Question 69

When should surgical closure be considered for an umbilical hernia?

Answer 69

If the sheath defect is more than 2 cm at 2 years of age, surgical closure is likely beneficial.

Question 70

What should be assessed to determine the need for surgical closure in an umbilical hernia?

Answer 70

The SHEATH defect, not the skin defect, should be assessed for the need for surgical closure.

Question 71

When is surgical closure usually deferred, and what is considered for very proboscoid skin?

Answer 71

Surgical closure is usually deferred until after 5 years of age to allow for possible spontaneous closure. If the skin is very proboscoid, umbilicoplasty (skin resection) may be considered.