Umbilical Polyp - Calgary Emergency Medicine

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Acute Umbilical Complaints
in the Pediatric ER
Or
“my babies navel looks/smells
funny”
Issues Umbilical - Case 1
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9 week girl infant. Presents to PLC-ER
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Swelling of the umbilicus for ~5 hours
Erythema and a central Umbilical “lump”
noted
No fever
Some poor feeding with no vomiting for less
than a day
~6 wet diapers past 24 hours
2
Issues Umbilical - Case 1
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5.11 kg, Cap refill <3 sec
T 36.4, R28, P 145, BP 78/49
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Alert, no distress
N H&N
N chest and HS
Soft benign abdomen with no masses
Central, red umbilical bulge within skin cuff
(cushion)
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Small volume thin purulent drainage?
Slight erythema 4-7o’clock? No induration or
demarcation
3
Issues Umbilical
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Referred to ACH-ER with:
“? Umbilical hernia, R/O Omphalitis”
ACH ER exam similar overall
• C&S of Umbilical “discharge”
• CBC, Lytes
• Felt likely to be Omphalitis
• Referral to General Surgery
• Ancef 25 mg/kg commenced
4
Issues Umbilical
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CBC
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WBC 9.7, Neuts 2.6
Hb 106, Platlets 522
Na 138, Cl 103, K 4.7, HCO3 23
Cr 17, Urea 2.2
U/A neg
5
Issues Umbilical
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General Surgical Opinion (in the am!)
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Likely omphalitis
Consider infected urachal remnant
Admitted
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Change to IV clindamycin
U/S booked
6
Issues umbilical
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In Hospital course
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Always remained afebrile
C&S umbilical discharge “scant skin flora
only”
U/S abdomen:
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Swollen protruding umbilicus noted to be filled
with echogenic material. A sinus tract is identified
which extends form the lower umbilicus and
connects to the superior and anterior wall of the
bladder in the midline. The appearance is
consistent with a patent urachus.
7
Issues Umbilical
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Day 4
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Discharged home for urgent elective repair
to be booked
Clindamycin oral course
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Objectives of Naval Mission
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Discuss omphalitis
Discuss common cord care
Understand the non-infectious
abnormalities that can occur in the
umbilicus, notably in the infant
Not to discuss
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Umbilical hernia management
Case room cord examination and
implications
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Normal Cord care
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Policies vary greatly in developing vs
developed countries
Marked decrease in incidence of Omphalitis in
developed countries
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In developed countries:
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~0.7% vs up to 6 %
Cochrane review shows no form of cord
cleaning/antiseptic is better than dry cord care
In developing countries antiseptics in cord care
markedly decrease death and omphalitis
(chlorhexidine, AgSulfadiazine, Triple dye…)
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Cord Separation
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Normal timing of ~1 week or less for
separation
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Prolonged by certain agents
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70% alcohol: ~17 days
Triple dye: 3-8 weeks
True “delayed” separation (without agent
application) is in excess of 3 weeks
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Umbilical infection
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All cords are nearly immediately
colonized
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Staph and other gm+ves within hours
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Devitalized tissue is a good bacterial
growth medium
Mild discharge and absent inflammatory
change, even with some odor is usually
still a normal occurrence.
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Enteric organisms shortly thereafter
No proof for or against Rx with Alcohol, Bacitracin or
Mupirocin…but many choose this.
When does this constitute early Omphalitis?
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Omphalitis
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Predominately Neonatal
Mean age of onset in term infants is 3.5
days
Infection of umbilicus and/or surrounding
tissues
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Purulent (+/-bloody) drainage from stump
Surrounding induration, erythema,
tenderness
BUT
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Lethargy, fever, Irritability, poor feeding
suggest more severe infection/impending
sepsis
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Omphalitis
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Complications:
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Sepsis / death
Septic umbilical arteritis/portal vein thrombosis
Peritonitis/liver abscess/intestinal gangrene
Small bowel evisceration
Necrotizing fasciitis
Present-day Mortality:
7-15%
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Case 2
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14 day infant girl transferred to ACH-ICU
for umbilical infection
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41 weeks GA
C/S for fetal distress
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APGARs 81 & 95
GBS+ve
Passed N mec. At 24 hours
No jaundice
Breast fed/BM 8x/day
Cord loss ~1 week of age
15
Case 2
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Day 11
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Some peri-umbilical redness, afebrile
Poor evening feeding
Day 12
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Worsening erythema, wider area
Abdomen appeared “puffy”
T = 38.50C
To local community hospital; blood-streaked stool in
ED, and with all serial later BMs
Much worse feeding and lethargy
Sepsis workup/LP/Ampicillin and Cefotaxime and
admitted
16
Case 2
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Day 13
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General progression of anorexia, and
increasing abdo wall abnormalities.
U/S abdomen, and transferred to ACH
overnight
Day 14 ACH - PICU
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Change to Flagyl, Meropenum, Clindamycin.
And Gentamycin
Surgery/Plastics consult
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Case 2
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Physical
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88/60, 153,100%RA, 37.5, 40, 4.0Kg
AF flat, no jaundice
CVS N save CRT “2-5 seconds”
No increased WOB
Mottled extremities
Distended abdomen. Black umbilicus,
surrounded by an inner purple and outer
white halo, both non-blanching. Rt > Lt,
~30% of abdo wall
Whole remainder of abdomen wall is
erythematous
18
Case 2
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Lab
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WBC of 33.7
CRP 72.8
Hb 148, Platlets 501
To ACH-OR for debridement, and bowel
inspection for R/O NEC
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Abdo wall biopsy and C&S
Bowel observed to be vital without NEC
Umbilicus and surrounding tissues resected
including necrotic skin and abdo. wall to healthy
fascia
Frozen section biopsy consistent with Nec Faciitis
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Case 2: Intra-operative, Post Umbilical
Resection
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Case 2: Intra-operative, Post Umbilical
Resection
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Case 2
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OR visits on PICU-days 1,2,4,6 and 8 for
serial lesser debridements and bowel
inspection
Wound closure PICU day 8 but
subsequent dehisence day 19
Change to tazocin/vancomycin day 7
Wound grew
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Enterococcus faecalis
Coag neg Staph
Actinomyces
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Case 2
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Day 12 - extubated
Day 13 - to the ward
Day 19 - Wound dehisced
Day 30 - discharged home
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All Abx discontinued
planned delayed closure abdo. wall ~2
weeks later
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Omphalitis
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Risk factors
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LBW
Prolonged labor
PROM
Non-sterile delivery
Umb.A. cathetrization
Home birth
Improper cord care
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(cow dung, bentonite
clay)
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Poorer Prognosis
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Male
Premature
“Septic delivery”
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(including un-planned
home delivery)
Temperature instability
Necrotizing fasciitis
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(up to 85% mortality)
Immune abnormalities
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Omphalitis/Any Soft Tissue Infection
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There is a continuum of severity:
Cellulitis
Infection of skin and S.C. fat
Necrotizing fasciitis
Infection of skin, S.C. fat and superficial and deep fasciae
Myositis/myonecrosis
Deep muscle infection with muscle death
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Omphalitis/Any Aggressive Soft Tissue
Infection
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Should be presumed to be poly-microbial at outset
“the usual suspects” in Omphalitis:
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Staph Aureus
Gp A Strep
Coag Neg Staph
Enterococci
Gm Negs: E Coli, Klebsiella P., Proteus Mirabilis…
Anerobes: Bacteroides, Clostridium
perfingens/tetani
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Omphalitis
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Pathology of infection is presumed to be
polymicrobial from the outset
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Abx must cover for this, and include:
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Anti-stahpylococcal penicilin or vancomycin
Aminoglycoside
Probable Clinamycin or Metronidazole
Esp. if maternal chorioamnionitis and/or foul
discharge, for anaerobic coverage
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Omphalitis
• Necrotizing Fasciitis
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Rare complication of omphalitis
Polymicrobial
Involves skin, subcutis, superficial and deep
fasciae
Rapid spread is typical
Bacteremia, systemic toxicity, and shock in
high proportion. Death 60-85%
Early aggressive surgical intervention, broad
spectrum antibiotics, and supportive ICU
care
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Case 3
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38 2/7 week boy
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30 yr G1P1 mother, N Vtx Vag delivery
APGARs 81 and 85
Short ACH transfer Day 1-3 for ?ileal
atresia…final Dx Meconium plug
Day 13
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Peri-umbilical redness noted by family
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Case 3
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Day 14
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Admitted to local hospital
Dx Omphalitis
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Ampicillin and Gentamycin
Day 15
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Increasing redness in abrupt fashion: 5cm
above and 3cm below umbilicus
Transfer to ACH ICU
Dx Omphalitis, R/O Necrotizing Fasciitis
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Case 3
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ICU:
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Not toxic
Abdo wall is only abnormality of serious note
WBC 16.5, N diff, INR N, Lytes N and Neg AG
Urgent tissue biopsy
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No Nec Fasciitis; consistent with cellulitis
Neg gram stain
Neg blood and urine C&S.
Surface Umb C&S from Primary hospital
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Coag neg staph, and enterococcus faecalis
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Case 3
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I.D. Service: Antibiotics changed to
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Meropenum, Clindamycin, and Gentamycin
Day 16
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Child improves sufficiently that ward transfer
is in process…..then oliguria unresponsive
to fluids arises
Scrotal swelling and severe progressive
abdominal wall edema
ICU stay maintained
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Case 3
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Day 17
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03:00 Resp failure/ETT
05:00 dobutamine infusion
05-10:00 progressive metabolic acidosis
10:00 to OR
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Abdominal exploration. Healthy bowel.
Abdo wall : Excision of navel and surrounding
tissue. Biopsy now positive for Necrotizing fasciitis
Deterioration:
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with coagulopathy, WBC up to 49.5, INR elevated,
ARDS / pulmonary hemorrhage
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Case 3
• Day 17
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Progressive deterioration and difficulty
ventilating. Rising Cr up to 180
13:30 back to OR
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Abdominal compartment syndrome
Bowel “eviscerates” under pressure and
ventilatability markedly improves…bowel
seems healthy; Abdo Wall Margins still look
healthy, and back to ICU with bowel
encased in a “silo bag”
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Case 3
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Severe oliguria
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Lines placed and dialysis commenced
Poor tolerance with repeated hypotension and need
for fluid bolusing
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Day 18
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Several bradycardic arrests
Progressive instablilty and dialysis
discontinued
Family agree to discontinue all supportive Rx
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04:20 child pronounced
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Case 3
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C&S from initial umbilical ACH biopsy
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Coag neg staph
Enterococcus faecalis
Clostridium sordellii
Autopsy conclusion
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Necrotizing faciitis of poly-microbial nature
Sepsis
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Conclusion
Respect Omphalitis
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Something is wrong with my
babies Navel
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Umbilical Granuloma
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Omphalo-mesenteric duct remnants
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Urachal remnants
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Case 4
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12 day infant girl
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41 3/7 weeks, vacuum assisted SVD
GBS -ve
Thriving
Cord dehisced day 7
Umbilicus raw, oozing with sero-sanguinous
discharge since
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Case 4
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Looks well
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P 165, R 26, T 37.1, BP 76/42
General Exam Normal
No peri-umbilical redness
Moist “nodule” of pinkish-red tissue over
stump site. Bleeds easily
?Umbilical Granuloma (vs some other
developmental lesion)…Referred to
Surgery Clinic DDR
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Case 4
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In clinic 1 month later
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Major lump had “fallen off” and moist base
was cauterized with AgNO3
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Re seen 3 weeks later:
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Area dry and fully healed
Diagnosis:
Umbilical Granuloma
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Umbilical Granuloma
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Most common cause of umbilical mass
and umbilical drainage
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Usually post cord separation
Persistent drainage of serous or serosanguinous fluid around the umbilicus
A mass of pink granulation tissue at
umbilical base
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Moist
Pink
Friable
Soft
Often pedunculated
Usually 3-10 mm
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Umbilical Granuloma
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Treatment:
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AgNO3 local Rx 1-2 x per week
If it persists post 3-4 Rx sessions
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Can be ligated (be sure its not a polyp!) or
referred to general surgery for formal excision
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Omphalo-mesenteric Duct
Remnants
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Omphalo-mesenteric duct (Viteline
duct):
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Connects the developing GI tract to yolk
sack
Regresses by ~9th week GA
Disruption of this regression causes the list
of abnormalities:
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Vitelline, or Omphalomesenteric Duct
Embryology
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OMD Remnants
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Umbilical fistula
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Complete patency of OMD with stoma-like
connection to the terminal ileum
Partial persistence of OMD
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Fibrous band umbilicus to ileum
“Distal” remnant - OMD-enteric cyst
“Proximal” remnant - Meckel’s diverticulum
Umbilical polyp - a mucosal remnant in the
umbilical stump
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OMD remnants
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Fibrous band
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can cause volvulus; obstruction and/or volvulus
are most common infant presentation
Umbilical Polyp
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Usually enteric, but occasionally urachal origin.
Rarely pancreas, liver
Firm masses. No response to AgNO3,and must be
surgically excised
OMD cyst
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often asymptomatic, or may be an umbilical or
abdominal mass; occasionally infected
48
Urachal Remnants
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Urachus is the embryologic descendant
of the allantois.
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Allantois is the most distal projection of
the primitive gut, projecting into the
extra-embryonic cord. Of it’s Intraembryonic portions:
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The bladder = proximal portion.
The urachus = more distal portion.
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The Allantois
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Urachal Remnants
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Urachal fistula - complete patency of the
urachus
Urachal cyst - remnant along tract
(usually lower 1/3)
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Urachal sinus
Blind umbilical tract, unconnected to the bladder
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Vesico-urachal diverticulum
Antero-superior midline bladder dome
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Umbilical (urachal) polyp
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Urachal Remnants
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Ultrasound is the ideal investigation for
initial definition
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Sinogram for patent urachus (“fistula”) or
urachal sinus are other options
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Renal U/S and VCUG have also been
recommended
53
Urachal Remnants
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Presentations:
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May be subtle with erythema +/- drainage
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Umbilical discharge or Omphalitis spectrum
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Umbilical pain or retraction on micturition
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Umbilical mass or cyst
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Peri-umbilical pain
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Urachal Remnants
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All need to be excised
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In adults, 50% have malignant
(adneocarcinoma) changes at the time of
excision (nil in children)
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Cuff of normal bladder mucosa is excised
during resection
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Questions?
56
References
1)
2)
3)
4)
5)
6)
Vane D.W. et al “Viteline Duct Abnormalities:
Experience with 217 Childhood Cases Arch
surg122:542, 1987
Pomeranz A. “Anomalies, Abnormalities and Care of
the Umbilicus” Pediatric Clinics of N.A. 51:819, 2004
Rescorla F. J. “Hernias and Umbilicus” in Principles
and Practice of Pediatric Surgery, volume 2, 2005
Cilento B. G. et al “Urachal Anomalies: Defining the
Best Diagnostic Modalitiy” Urology52:120, 1998.
Ashley R.A. et al “Urachal Anomalies: a Longitudinal
Study of Urachal Remnants in Children and Adults” J
Urol 178:1615, 2007
Cushing A.H. “Omphalitis: A Review”Pediatr Infect Dis
2:282, 1985
57
References
7) Sawardekar K.P. “changing Spectrum of Neonatal
Omphalitis” Pediatr Infect Dis J 23:22, 2004
8) Mason W.H.et al “Omphalitis in the Newborn
Infant”Pediatr Inf Dis J 8:521, 1989
9) Kosloske A.M. “Cellulitis and Necrotizing Fasciitis of the
Abdominal Wall in Pediatric Patients”. J Pediatric Surg
16:246-251, 1981
10)Simon N.P. “Changes in Newborn Bathing Practices
may Increase the Risk for Omphalitis” Clin Pediatr
43>763-767, 2004
11) Louie J.P. “Essential Diagnosis of Abdominal
Emergencies in the First Year of Life”Emer Med.
Clinics of N A 25:1009-1040
12) Zupan J. et al “Topical Umbilical Cord Care at
Birth(Review)”Cochrane Library 2008, Issue 3
58
References
13) Mullany L.C et al “Development of a Clinical Sign Based
Algorithm for Community Based Assessment of
Omphalitis” Arch Dis. Child. Fetal Neonatal Ed. 91:F91F104, 2006
14) Mullany, L.C. “Topical Applications of Chlorhexidine to the
Umbilical Cord for Prevention of Omphalitis and Neonatal
Mortality n Southern Nepal: a Community-based, Clusterrandomized Trial” Lancet 367:910, 2006
15) Hseih, W.S. et al “Neonatal Necrotizing Fasciitis: A report
of Three Cases abd Review of the Literature”
Pediatrics103:e53, 1999
16) Iacono, G. “Red Umbilicus”:a Diagnostic Sign of Cow’s
Milk Protein Intolerance. J. Ped.Gastro. And Nutr. 42:531534, 2006
17) Burd R.S. et al “Evaluation and Initial Management of
Miscellaneous Pediatric Surgical Problems”Pediatric
Annals30:752-759, 2001
59
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