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
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
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.