Umbilicus

Diseases of the umbilicus

• Inflammation

                  Infection of the stump of the
                   umbilical cord (omphalitis)

                   Umbilical granuloma
                   Umbilical dermatitis
                   Pilonidal sinus
• Fistula                 

 Faecal

             Patent vitellointestinal duct

             Neoplastic ulceration from the transverse colon

             Tuberculous peritonitis

 

Urinary = Patent urachus

                  Biliary

                 

• Neoplasms

  Benign

               Adenoma (raspberry tumour)

               Endometrioma

 Malignant                   

Primary

Secondary

                  Stomach

                  Colon, including the rectum

                  Ovary and uterus

                  Breast

Hernia

Umbilical calculus

Eversion (in ascites)

Inflammation of the umbilicus

Infection of the umbilical cord

By the third or fourth day post delivery the stump of the umbilical cord is found to be carrying staphylococci in over 50 per cent of babies born in maternity hospitals. Less commonly, the stump of the cord harbours streptococci, and epidemics of puerperal sepsis in maternity hospitals have been traced to the umbilical cord of one infant in the nursery thus infected. Escherichia coli and Clostridium tetani (causing neonatal tetanus) are other possible invaders. The chief prophylaxis is strict asepsis during severance of the cord and the use of 0.1 per cent chlorhexidine, locally, for a few days.

Omphalitis. The incidence of an infected umbilicus is much higher in communities that do not practise aseptic severance of the umbilical cord. When the stump of the umbilical cord becomes inflamed, antibiotic therapy usually localises the inflammation. By employing warm moist dressings, the crusts separate, giving exit to pus. Exuberant granulation tissue requires a touch of silver nitrate. In more serious cases infection is liable to spread along the defunct hypogastric arteries or umbilical vein when, in all probability, one or other of the following complications will supervene.

Abscess of the abdominal wall. If gentle pressure is exerted above or below the navel, and a bead of pus exudes at the navel, a deep abscess associated with one of the defunct umbilical vessels is present. This must be opened. A probe is passed into the sinus to determine its direction and this is followed by a grooved director on to which the skin and overlying tissues are incised in the midline.

Extensive ulceration of the abdominal wall. Extensive ulceration of the abdominal wall due to synergistic infection is treated in the same way as postoperative subcutaneous gangrene (vide infra).

Septicaemia. Septicaemia can occur from organisms entering the bloodstream via the umbilical vein. Jaundice is often the first sign. An abscess in the abdominal wall above the umbilicus should be sought. In other respects the treatment of this grave complication follows the usual lines (Chapter 4).

Jaundice in the newborn. Infection reaching the liver via the umbilical vein may cause a stenosing intrahepatic cholangiolitis, appearing some 3—6 weeks after birth.

Portal vein thrombosis. Portal vein thrombosis and subsequent portal hypertension.

Peritonitis. Peritonitis carries a bad prognosis.

Umbilical hernia.

Umbilical granuloma. Chronic infection of the umbilical cicatrix which continues for weeks causes granulation tissue to pout at the umbilicus. There is no certain means of distinguishing this condition from an adenoma. Usually an umbilical granuloma can be treated by one application of silver nitrate followed by dry dressings, but an adenoma soon recurs in spite of these measures.

Dermatitis of and around the umbilicus. This is common at all times of life. Fungal and parasitic infections are more difficult to eradicate from the umbilicus than from the skin of the abdomen. Sometimes the dermatitis is consequent upon a discharge from the umbilicus, as is the case when an umbilical fistula or a sinus is present. In overweight women intertrigo occurs.

A deep, tender swelling in the midline below the umbilicus signifies an abscess present in the extraperitoneal fat and is usually due to an infected urachal remnant. Exploration and proper drainage are necessary.

Pilonidal sinus. Pilonidal sinus (a sinus containing a sheath of hairs) is sometimes encountered. It should be excised.

Umbilical calculus (umbolitli). This is often black in colour, and is composed of desquamated epithelium which becomes inspissated and collects in the deep recess of the umbilicus. The treatment is to dilate the orifice and extract the calculus but, to prevent recurrence, it may be necessary to excise the umbilicus.

Umbilical fistulae

The umbilicus being a central abdominal scar, it is understandable that a slow leak from any viscus is liable to track to the surface at this point. Added to this, very occasionally, the vitellointestinal duct or the urachus remains patent; consequently it has been aptly remarked that the umbilicus is a creek into which many fistulous streams may open.

For instance, an enlarged inflamed gallbladder perforating at its fundus may discharge gallstones through the umbilicus. Again, an unremitting flow of pus from a fistula at the umbilicus of a middle-aged women led to the discovery of a length of gauze overlooked during a hysterectomy 5 years previously.

The vitellointestinal duct. The vitellointestinal duct occasionally persists and gives rise to one of the following conditions.

It remains patent (Fig. 62.20a). The resulting umbilical fistula discharges mucus and, rarely, faeces. Often a small portion only of the duct near the umbilicus remains un obliterated. This gives rise to a sinus that discharges mucus. The epithelial lining of the sinus often becomes everted to form an adenoma.

Sometimes both the umbilical and the intestinal ends of the duct close, but the mucous membrane of the intervening portion remains and an intra-abdominal cyst develops (Fig. 62.20b).

With its lumen obliterated or unobliterated, the vitellointestinal duct provides an intraperitoneal band (Fig. 62.20c) which is a potential danger, for intestinal obstruction is liable to occur. The obstruction results from a coil of small intestine passing under or over or becoming twisted around the band.

Such a band may contract and pull a Meckel’s diverticulum into a congenital umbilical hernia (Fig. 62.20d).

A vitellointestinal cord connected to a Meckel’s diverticulum, but not attached to the umbilicus, becomes adherent to, or knotted around, another loop of small intestine and so causes intestinal obstruction.

Sometimes a band extending from the umbilicus is attached to the mesentery near its junction with a distal part of the ileum. In this case the band is probably an obliterated vitelline artery and is not necessarily associated with a Meckel’s diverticulum.

Treatment. A patent vitellointestinal duct should be excised together with a Meckel’s diverticulum, if one is present, preferably when the child is about 6 months old. When a vitellointestinal band gives rise to acute intestinal obstruction, after removing the obstruction by dividing the band, it is expedient, where possible, to excise the band and bury the cut ends.

Patent urachus. A patent urachus seldom reveals itself until maturity or even old age. This is because the contractions of the bladder commence at the apex of the organ and pass towards the base. A patent urachus, because it opens into the apex of the bladder, is closed temporarily during micturition and so the potential urinary stream to the bladder is cut off. Therefore the fistula remains unobtrusive until a time when the organ is overfull, usually due to some form of obstruction.

Treatment. Treatment is directed to removing the obstruction to the lower urinary tract. If, after this has been remedied, the leak continues or a cyst develops in connection with the urachus, umbilectomy and excision of the urachus down to its insertion into the apex of the bladder, with closure of the latter, is indicated.

Neoplasms of the umbilicus

Umbilical adenoma or raspberry tumour is commonly seen in infants (Fig. 62.21), but only occasionally later in life. It is due to a partially (occasionally a completely) unobliterated vitellointestinal duct. Mucosa prolapsing through the umbilicus gives rise to a raspberry-like tumour, which is moist and tends to bleed.

Treatment

If the tumour is pedunculated, a ligature is tied around it and, in a few days, the polypus drops off. Should the tumour reappear after this procedure, umbilectomy is indicated. Sometimes a patent vitellointestinal duct, or more often a vitellointestinal band, will be found associated with a Meckel’s diverticulum. The Meckel’s diverticulum and the attached cord or duct should be excised at the same time as the umbilicus. Histologically, the tumour at the umbilicus consists of columnar epithelium rich in goblet cells.

Endometrioma. Endometrioma occurs in women between the ages of 20 and 45 years. On histological examination it is found to consist of endometrial glands occupying the same plane in the dermis as the sudoriferous glands and opening on to the surface in the same way. The umbilicus becomes painful and bleeds at each menstruation, when the small fleshy tumour between the folds of the umbilicus becomes more apparent. Occasionally an umbilical endometrioma is accompanied by endometriomas in the uterus or ovary. When, as is usually the case, the tumour is solitary, umbilectomy will cure the condition.

Secondary carcinoma. Secondary carcinoma at the umbilicus (or Sister Joseph’s nodule)4 (Fig. 62.22) is not very uncommon, but it is always a late manifestation of the disease. The primary neoplasm is often situated in the stomach, colon or ovary, but a metastasis from the breast, probably transmitted along the lymphatics of the round ligament of the liver, is sometimes located here.