Umbilical Pathology Flashcards
What are some common pathologies associated with the umbilicus?
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.
What is the cause of stool discharge from the umbilicus?
Stool discharge from the umbilicus is caused by a patent vitello-intestinal duct.
What is the cause of urine discharge from the umbilicus?
Urine discharge from the umbilicus is caused by a patent urachus.
What conditions can cause purulent discharge from the umbilicus?
Purulent discharge can result from an umbilical granuloma, omphalitis, or a tuberculosis (TB) fistula.
What conditions can cause bloody discharge from the umbilicus?
Bloody discharge can be due to cord trauma or an umbilical granuloma.
When does the opening between the mid-portion of the digestive tube and the yolk sac appear, and when is it usually obliterated?
The opening appears during the 4th week of gestation and is typically obliterated by the 7th to 9th week.
What is the function of the yolk sac during early embryonic development?
The yolk sac (umbilical vesicle) provides nutrition to the early embryo via the vitelline artery.
What can happen if remnants of the vitello-intestinal duct persist?
Persistent remnants can lead to a spectrum of congenital malformations.
How common are persistent remnants of the vitelline duct in the population?
They occur in 0.2 to 4% of the population.
How common is a patent vitelline duct among live births?
A patent vitelline duct occurs in fewer than 1 in 5000 live births.
What is the most common anatomical variant of vitelline duct remnants?
Meckel’s diverticulum.
What is the most common presentation of Meckel’s diverticulum in children?
Bleeding from ectopic gastric mucosa, causing mucosal ulceration at the base of the diverticulum.
How does Meckel’s diverticulum commonly cause bowel obstruction?
Through small bowel intussusception, which is the presenting problem in about 20% of symptomatic patients, typically at around 2 years of age.
How does diverticulitis from Meckel’s diverticulum typically present?
Abdominal pain due to diverticulitis is rare and may progress to perforation. It is often diagnosed during surgery for suspected appendicitis.
What imaging technique is used to detect ectopic gastric or bleeding mucosa in Meckel’s diverticulum?
Nuclear scintigraphy (Meckel scan) or red cell scan is useful, especially when endoscopy is negative.
When is diagnostic laparotomy considered in Meckel’s diverticulum?
It may be performed if bleeding persists despite a negative Meckel scan.
What is the recommended surgical management for asymptomatic incidentally discovered Meckel’s diverticulum?
Surgical excision is recommended unless the base is very wide and the lesion is short, with no visible or palpable ectopic mucosa.
When might resection and anastomosis be necessary in Meckel’s diverticulum?
If there is significant ulceration at the mesenteric aspect of the diverticulum.
How does a vitelline fistula typically present?
As a sinus draining dark fluid or stool from the umbilicus.
What imaging technique is useful to confirm the diagnosis of a vitelline fistula?
A fistulogram is useful before surgical exploration and resection.
What is the role of a fibrous band and persistent vitelline artery in the context of Meckel’s diverticulum?
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.
What is the risk associated with the fibrous band connecting the bowel to the umbilicus?
The fibrous band poses a risk for volvulus around the band, leading to signs of bowel obstruction.
How is bowel obstruction caused by a fibrous band managed?
Management includes NGT drainage, NPO (nil by mouth), IV fluid resuscitation, and antibiotics.
What is the surgical approach if bowel necrosis occurs due to a persistent fibrous band?
Surgical exploration and division of the fibrous band, with bowel resection if complicated by necrosis.
How does an umbilical sinus typically present?
It presents with mucous drainage from a small defect at the umbilicus.
What diagnostic technique is useful to exclude a fistula before surgical exploration in the case of an umbilical sinus?
A contrast study is useful to exclude a fistula before surgical exploration and resection.
What are the likely presenting symptoms of an umbilical cyst?
Bowel obstruction (especially if within a persistent fibrous band with volvulus) or sepsis (infection with purulent contents).
Can an umbilical cyst be palpated?
Yes, a mass may be palpable if the cyst is superficial
What is the differential diagnosis of a cystic lesion at the umbilicus?
The differential diagnosis includes a urachal cyst (more superficial, no bowel communication but may become infected) and a duplication cyst
What are the diagnostic methods used to establish the diagnosis of an umbilical cyst?
Ultrasound or exploratory laparotomy usually establishes the diagnosis.
What is the treatment for an umbilical cyst?
Surgical excision is required.
How does an umbilical polyp typically present?
As a glistening “red cherry” at the umbilicus from birth, caused by persistent gastrointestinal mucosa.
A pyogenic granuloma, which appears a few weeks after birth and can be treated with topical table salt or silver nitrate stick application.
How is a true umbilical polyp treated?
It requires umbilical exploration under general anesthesia with resection of the ectopic mucosa.
Where can luminal narrowing in the midgut occur?
It may occur at the previous site of the vitelline duct.
How does luminal narrowing in the midgut typically present?
It is rarely symptomatic but may present with bowel obstruction.
What is the management for luminal narrowing in the midgut causing bowel obstruction?
Surgical exploration is required if bowel obstruction occurs.
What is the prevalence of Meckel’s diverticulum in the population?
Meckel’s diverticulum occurs in 2% of the population, with an incidence range of 0.2 to 4%.
What percentage of individuals with Meckel’s diverticulum are symptomatic?
It is symptomatic in 2% of cases, though complications occur in approximately 5%.
How does Meckel’s diverticulum present in terms of gender?
It is twice as common in males compared to females.
At what age does Meckel’s diverticulum usually present?
It typically presents before 2 years of age.
Where is Meckel’s diverticulum usually located in the small bowel?
It is usually located within 2 feet (50 cm) of the ileocecal valve on the antimesenteric aspect of the small bowel.
What is the typical length of Meckel’s diverticulum?
Meckel’s diverticulum is usually about 2 inches (5 cm) long.
What types of ectopic mucosa are typically found in Meckel’s diverticulum?
It may contain up to two types of ectopic mucosa, usually gastric (in 2/3 of cases) and occasionally pancreatic (2 to 6%).
How does an umbilical granuloma typically form?
It may occur when the umbilical cord falls off, leaving some exposed mucosa.
What is the treatment for an umbilical granuloma?
Treatment options include silver nitrate application or, if persistent, tying the granuloma at the base.
How can an umbilical granuloma be differentiated from a true umbilical polyp?
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.
What is omphalitis?
Omphalitis is a serious infective condition that can progress rapidly to severe sepsis and death, typically occurring in newborns and young babies.
How can omphalitis be prevented?
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.
What is the treatment for omphalitis?
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.
How should cellulitis surrounding the umbilicus be managed in cases of omphalitis?
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.
Why is necrotizing fasciitis a concern in omphalitis, and how should it be managed?
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.
When does a tuberculous fistula typically occur, and how does it present?
It can occur in older patients, following an abscess that spontaneously drains, and may be associated with an enterocutaneous fistula.
How is tuberculous fistula diagnosed?
The diagnosis is confirmed through clinical evaluation and appropriate investigations, such as imaging and culture, to detect Mycobacterium tuberculosis.
What is the management approach for a tuberculous fistula?
Conservative management with tuberculosis drugs may lead to resolution, provided there is no distal bowel obstruction from tuberculous adhesions or strictures.
What is patent urachus, and how does it present?
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.
What is the embryological origin of the urachus, and how does it develop?
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.
How is patent urachus diagnosed?
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.
What is the management approach for patent urachus?
The condition is managed with surgical closure after ruling out underlying bladder outlet obstruction, such as posterior urethral valves or neurogenic bladder.
What is cord trauma, and how is it commonly presented in neonates?
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.
How should cord trauma be evaluated in neonates?
Carefully evaluate for any necrotic tissue that may require debridement, or for signs of ectopic mucosa from an umbilical polyp.
How can early formation of an umbilical granuloma be treated?
Topical table salt can help prevent and treat early formation of an umbilical granuloma.
What is an umbilical hernia, and where is it located?
An umbilical hernia is a small residual sheath defect at the insertion of the umbilical cord.
How does an umbilical hernia evolve over time?
The hernia narrows down over time in most people due to contractile fibers around the defect within the sheath edges.
What is the risk of incarceration in an umbilical hernia, and what may become incarcerated?
The risk of incarceration of bowel is very low, but rarely omentum can become incarcerated, causing pain and an irreducible swelling.
What are the risk factors for umbilical hernias and complications?
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.
When is urgent surgical repair required for an umbilical hernia?
Urgent surgical repair is required for acute presentations with incarceration.
What rule can be used to determine which non-complicated umbilical hernias will close spontaneously?
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.
When should surgical closure be considered for an umbilical hernia?
If the sheath defect is more than 2 cm at 2 years of age, surgical closure is likely beneficial.
What should be assessed to determine the need for surgical closure in an umbilical hernia?
The SHEATH defect, not the skin defect, should be assessed for the need for surgical closure.
When is surgical closure usually deferred, and what is considered for very proboscoid skin?
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.
