Visual Diagnosis

Visual Diagnosis

Things That Can Happen to Your
Belly Button
Kathleen Forcier

Case of Umbilical Drainage
• 1 mo old ex FT F with persistent umbilical
drainage
• Cord fell off at 2 weeks of life
• History of umbilical granuloma s/p silver
nitrate@2 ½ weeks old

• Afebrile
Physical Exam
• Gen: alert, NAD, shirt has 1 inch area of
moisture
• Chest: CTAB
• CV: no murmurs, 2 + femoral pulses b/l
• Abd: umbilicus glistens/wet, no purulent
discharge, no granuloma, no surrounding
erythema, normal BS, no HSM

Differential Diagnosis

Studies?

Our Patient
• Pyridium PO x 1 day – looking to see if
discharge turned orange
• Orange umbilical discharge = patent urachus,
if not may be urachal cyst
• Keflex ppx
• Abd U/S, Renal U/S, VCUG

Results
• No orange drainage from
umbilicus (not a true
patent urachus)
• U/S showed “anechoic
tubular structure extending
from the dome of the
bladder to the umbilicus
with 1 cm x 0.8 cm cystic
structure seen approx 2 cm
from bladder dome”

What We’ll Cover
• Embryology review of umbilical cord contents
• Omphalomesenteric duct anomalies
• Urachal anomalies
• Other common umbilical findings

Embryology
• 4 th week the umbilical cord contains the umbilical
vessels, the urachus and the omphalomesenteric
duct.
• The omphalomesenteric duct connects the gut to
the yolk sac (involutes 9 th week of gestation)
• The allantois (diverticulum of the hindgut)
becomes the urachus and connects the bladder
to the umbilicus (involutes to become the median
umbilical ligament in month 5 of gestation)

Problems with Omphalomesenteric Duct

Meckel’s Diverticulum
• Painless rectal bleeding from ectopic gastric
mucosa
• Can be a lead point for intussusception

Patent Omphalomesenteric Duct
• Drainage from the
umbilicus (serous,
bilious, feculent)
• Dx with fistulogram –
inject dye into the
umbilicus and look for
contrast in the small
intestine

Visual Diagnosis

Fibrous Band
• Can result in volvulus and intestinal
obstruction

Problems of the Urachus

Symptoms
• 43% with umbilical drainage
• 40% of urachal cysts presented with infection
• 15% had palpable suprapubic mass
• Adults present with hematuria and pain, 51%
had evidence of adenocarcinoma on
histopathology
• Excision is controversial

Urachal Cyst
• Palpable periumbilical mass
• Infected cysts present with abdominal pain,
erythema, periumbilical swelling
• If the cyst ruptures into intraperitoneal space
it can cause acute abdomen
• Usual organism is Staph aureus

Patent Urachus
• Free communication between the bladder and
the umbilicus.
• Persistent wet draining cord
• Can cause UTIs
• May be a pop‐off valve in posterior urethral
valves

VCUG

Umbilical Granuloma
• Soft, moist, pink, friable lesion of granulation
tissue
• Can cause persistent drainage
• Treatment is silver nitrate

Umbilical Polyps
• Omphalomesenteric ductal or urachal
remnants
• Larger than granulomas
• Don’t respond to silver nitrate, require
surgical excision
• Send the tissue to path to determine if it is
urachal or omphalomesenteric origin

Omphalitis
• Infection of the umbilical stump or
surrounding tissue
• Erythema, induration, swelling of the skin
• Systemic signs may include lethargy, fever,
irritability, poor
feeding

Omphalitis
• Umbilicus grants access to the portal vein (via
umbilical vein) can cause portal vein
thrombosis or liver abscess
• Can cause peritonitis
• Can become necrotizing fasciitis
• Usually polymicrobial infection involving S.
aureus, GAS, and GN bacteria
• Treatment Amp + Gent, may need vanco

Umbilical Hernia
6‐10x more common in African Americans than
whites
Rarely incarcerate
Most resolve by 3 y/o
If present at 4 y/o
Unlikely to resolve on
its own

Single Umbilical Artery
• Occurs in

Delayed Separation
• Normal time to separation is about 1 week
• Presence of the cord past 3 weeks is
considered delayed
• Causes include immunodeficiency ( leukocyte
adhesion deficiency), urachal abnormality
• Evaluate neutrophil function in neonates with
delayed separation and signs of infection

Take Home Points
• Omphalomesenteric duct connects the small
bowel to the umbilicus
• Urachus connects the bladder to the
umbilicius
• Omphalitis is an emergency and requires
prompt antibiotics to prevent significant
morbidity

Sources
• Ashley et al. Urachal Anomalies: A Longitudinal Study of Urachal
Remnants in Children and Adults. The Journal of Urology. 2007:
178: 1615‐1618.
• Galati et al. Management of Urachal Remnants in Early Childhood.
The Journal of Urology. 2008; 180, 1824‐1827.
• Hinson et al. Picture of the Month. Archives of Pediatric and
Adolescent Medicine. 1997., 151: 1161‐1162.
• O’Donnell et al. Pediatric Umbilical Problems. Pediatric Clinics of
North America. 1998: 45; 4 791‐799.
• Palazzi and Brandt. Care of the umbilicus and management of
umbilical disorders. Up to Date. September 25, 2009.
• Pomeranz. Anomalies, abnormalities and care of the umbilicus.
Pediatric Clinics of North America. 2004: 51; 819‐827.
• Ueno et al. Urachal Anomalies: Ultrasonography and Management.
Jounral of Pediatric Surgery. 2003: 38; 1203‐1207.