Disorders of the Umbilicus Clinical Presentation

Updated: Apr 09, 2020
  • Author: Robert K Minkes, MD, PhD; Chief Editor: Eugene S Kim, MD, FACS, FAAP  more...
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Presentation

History and Physical Examination

Umbilical infections can occur because of an embryologic remnant or poor hygiene. Traditionally, gram-positive organisms, such as Staphylococcus aureus and Streptococcus pyogenes, were most commonly identified. Gram-negative and polymicrobial infections are seen today, especially in rapidly progressing cellulitis and necrotizing fasciitis.

Umbilical granulomas appear as 1-mm to 1-cm, pink, friable lesions at the base of the umbilicus. They produce variable amounts of drainage that can irritate the surrounding skin. An umbilical polyp is brighter red than a granuloma and represents retained intestinal or gastric mucosa from the vitelline duct.

The presentation of omphalomesenteric remnants depends on the specific type of defect (see the first image below). If a communication persists from the terminal ileum to the umbilicus, intestinal contents or stool can be observed leaking from the umbilicus. Prolapse of intestine through an omphalomesenteric fistula can also be observed (see the second image below). The drainage from a fistula that does not communicate with the ileum varies; it may be clear, bloody, or purulent. Cystic remnants may become infected and manifest with pain and swelling.

Omphalomesenteric duct remnants. (A) Meckel divert Omphalomesenteric duct remnants. (A) Meckel diverticulum. Note feeding vessel. (B) Meckel diverticulum attached to posterior surface of anterior abdominal wall by a fibrous cord. (C) Fibrous cord attaching ileum to abdominal wall. (D) Intestinal-umbilical fistula. Intestinal mucosa extends to skin surface. (E) Omphalomesenteric cyst arising in a fibrous cord. The cyst may contain intestinal or gastric mucosa. (F) Umbilical sinus ending in a fibrous cord attaching to the ileum. (G, H) Omphalomesenteric cyst and sinus without intestinal attachments.
Photograph of newborn with intestinal prolapse thr Photograph of newborn with intestinal prolapse through a patent omphalomesenteric duct. Both the proximal and distal limbs of the intestine have prolapsed. The umbilicus was explored, the bowel was easily reduced, and the patent duct was excised. The child was discharged from the hospital 2 days later.

The presentation of urachal remnants also varies. Clear drainage from the umbilicus is characteristic of a urachal fistula. Drainage of urine from the umbilicus may suggest bladder outlet obstruction and warrants further investigation.

A urachal cyst is usually discovered as a painful mass between the umbilicus and suprapubic area when it becomes infected. Pain and retraction of the umbilicus during urination may suggest a urachal anomaly. A urachal sinus manifests with drainage that can be clear or purulent and occurs through the umbilicus or midline skin below the umbilicus (see the image below).

Urachal sinus with purulent drainage in midline be Urachal sinus with purulent drainage in midline below the umbilicus (black arrow). A laparoscope was placed in the supraumbilical crease (red arrow) for mobilization of the internal portion of the urachal remnant as depicted in the next image.

Patients with umbilical hernias present early in life with bulging at the umbilicus. The swelling is most prominent when the infant or child is crying or straining. Umbilical hernias are usually asymptomatic and rarely cause pain. The skin can become severely stretched, which may be alarming to parents and physicians (see the image below). Parents often mention that the child plays with the redundant skin.

Preoperative photograph demonstrating umbilical he Preoperative photograph demonstrating umbilical hernia with redundant skin.

Incarceration, strangulation, bowel obstruction, erosion of the overlying skin, and bowel perforation are rare events in infants and small children. The risk of incarceration increases significantly in adults with umbilical hernias.

Patients with umbilical infections can present with drainage from the umbilicus, swelling, and redness. Cellulitis may rapidly progress and lead to necrotizing fasciitis. Necrotizing fasciitis is characterized by abdominal distention, tachycardia, purpura, leukocytosis, and other signs of sepsis despite antibiotic therapy.