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Pediatric Umbilical Abnormalities

Pediatric Umbilical Abnormalities. Scott Nguyen MD Mount Sinai School of Medicine Dept of Surgery. Abnormalities of Umbilical Cord. Umbilical abnormalities result from failure of umbilical ring to close or persistence of umbilical structures

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Pediatric Umbilical Abnormalities

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  1. Pediatric Umbilical Abnormalities Scott Nguyen MD Mount Sinai School of Medicine Dept of Surgery

  2. Abnormalities of Umbilical Cord • Umbilical abnormalities result from failure of umbilical ring to close or persistence of umbilical structures • Understanding embryology of cord is essential in understanding the pathophysiology of umbilical abnormalities

  3. Embryology - 3rd week

  4. Embryology

  5. Embrology

  6. Embryology • 6th wk – midgut loop elongates and herniates out through umbilical cord • Midgut rotates 270 degrees • Returns to abdomen by 10th wk • Anterior abdominal wall progressively closes leaving only umbilical ring

  7. Umbilical Abnormalities • Urachal Abnormalities • Vitelline Duct Abnormalities • Umbilical Hernia • Omphalitis • Delayed Cord Separation

  8. Umbilical granuloma

  9. Bladder forms from ventral portion of cloaca Bladder descends into pelvis w/ urachus connecting apex to umbilicus Usually urachus involutes to a fibrous cord – median umbilical ligament Urachal formation

  10. Urachal abnormalities • failure of obliteration of urachus resulting complete or partial patency of urachus • < 1/1000 live births • inflammation or drainage from umbilicus • US, CT, contrast studies, or injection of dye into tract can confirm diagnosis

  11. Patent Urachus (50%) Urachal cyst (30%) Urachal sinus (15%) Vesicourachal diverticulum (5%)

  12. Patent Urachus

  13. Studies • Catherization of tract and injection of dye • Voiding cystourethrogram • US

  14. Ultrasound

  15. CT

  16. VCUG

  17. Treatment Patent Urachus

  18. Patent Urachus

  19. Usually assx until infected Rarely become infected in newborn period, usu manifests as young adult Urachal Cyst

  20. Infected Urachal cyst • Fever, voiding symptoms, midline hypogastric tenderness, mass, UTI • May drain into bladder or umbilicus • Rarely can rupture into preperitoneal tissues or peritoneal cavity • Cultures - Staph Aureus

  21. US

  22. CT

  23. Infected Urachal cyst - treatment • Incision and drainage • Percutaneous drainage • Complete surgical excision of all urachal tissue • 30% recurrence if only drainage • Staged approach limits amount of bladder resected

  24. Becomes symptomatic when infected Tx – drainage and resection of urachal tissue Urachal Sinus

  25. Sinogram

  26. Blind sac at bladder apex Mostly assx Urachal Diverticulum

  27. Urachal Diverticulum

  28. Vitelline Duct Abnormalities

  29. Vitelline Duct • Vitelline Duct is connection between midgut and yolk sac • Usually involutes in 7th – 9th weeks

  30. Vitelline duct abnormalities

  31. Meckel’s Diverticulum

  32. Meckel’s Diverticulum • contains ectopic gastric or pancreatic mucosa • In 2% of population • 2 feet from ileocecal valve, antimesenteric border • Majority of symptomatic < 2yrs old

  33. Presentation • Painless GI Bleeding (50%) • Bowel Obstruction (30%) • Inflammation – diverticulitis (20%)

  34. GI Bleeding • Most common cause of bleeding in children • Painless, massive, usually self resolving • Due to mucosal ulceration from acid secretion

  35. Meckel’s Scan – GI bleeding

  36. Bowel Obstruction • Due to intussusception, diverticulum is the lead point • Sudden severe pain out of proportion to physical exam • Hydrostatic Barium enema diagnostic, rarely therapeutic

  37. Intussusception

  38. Intussusseption

  39. Meckel’s Diverticulitis • Sx like appendicitis • Result of lumenal obstruction, bacterial invasion, progressive inflammation • Ectopic gastric mucosa predisposes • 30% incidence of perforations • Higher risk of peritonitis

  40. Treatment • Surgical Resection without removal of ileum • V shaped incision at base • resection of involved segment of ileum w/ primary anastamosis

  41. Fibrous Vitelline Remnant

  42. Fibrous Vitelline Remnant

  43. Barium Enema

  44. Vitelline Umbilical Fistula

  45. Vitelline Umbilical fistula • Umbilical polyp • May drain enteric contents • Fistulogram shows communication w/ bowel

  46. Herniation

  47. Umbilical Hernia

  48. Umbilical hernia • Protrudes • Rarely incarcerates • Incidence 10-25% infants • 6-10x higher incidence in Black infants • More in girls, premature • Assoc w/ Down’s Synd, Beckwith-Wiedemann synd, hypothyroidism, mucopolysaccharidosis

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