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Pediatric Pediatric Umbilical Umbilical
AbnormalitiesAbnormalitiesScott Nguyen MDScott Nguyen MD
Mount Sinai School of MedicineMount Sinai School of Medicine
Dept of SurgeryDept of Surgery
Abnormalities of Abnormalities of Umbilical CordUmbilical Cord
Umbilical abnormalities result from Umbilical abnormalities result from failure of umbilical ring to close or failure of umbilical ring to close or persistence of umbilical structurespersistence of umbilical structures
Understanding embryology of cord is Understanding embryology of cord is essential in understanding the essential in understanding the pathophysiology of umbilical pathophysiology of umbilical abnormalitiesabnormalities
Embryology - 3Embryology - 3rdrd week week
EmbryologyEmbryology
EmbrologyEmbrology
EmbryologyEmbryology
66thth wk – midgut loop elongates and wk – midgut loop elongates and herniates out through umbilical cordherniates out through umbilical cord
Midgut rotates 270 degreesMidgut rotates 270 degrees Returns to abdomen by 10Returns to abdomen by 10thth wk wk Anterior abdominal wall Anterior abdominal wall
progressively closes leaving only progressively closes leaving only umbilical ringumbilical ring
Umbilical AbnormalitiesUmbilical Abnormalities
Urachal AbnormalitiesUrachal Abnormalities Vitelline Duct AbnormalitiesVitelline Duct Abnormalities Umbilical Hernia Umbilical Hernia OmphalitisOmphalitis Delayed Cord SeparationDelayed Cord Separation
Umbilical granulomaUmbilical granuloma
Urachal formationUrachal formation Bladder forms from Bladder forms from
ventral portion of ventral portion of cloacacloaca
Bladder descends Bladder descends into pelvis w/ into pelvis w/ urachus connecting urachus connecting apex to umbilicusapex to umbilicus
Usually urachus Usually urachus involutes to a involutes to a fibrous cord – fibrous cord – median umbilical median umbilical ligamentligament
Urachal abnormalitiesUrachal abnormalities
• failure of obliteration of urachus failure of obliteration of urachus resulting complete or partial patency resulting complete or partial patency of urachus of urachus
• < 1/1000 live births< 1/1000 live births• inflammation or drainage from inflammation or drainage from
umbilicusumbilicus• US, CT, contrast studies, or injection US, CT, contrast studies, or injection
of dye into tract can confirm of dye into tract can confirm diagnosis diagnosis
• Patent Urachus (50%)Patent Urachus (50%)• Urachal cyst (30%)Urachal cyst (30%)• Urachal sinus (15%)Urachal sinus (15%)• Vesicourachal diverticulum (5%) Vesicourachal diverticulum (5%)
Patent Urachus Patent Urachus
StudiesStudies
Catherization of tract Catherization of tract and injection of dyeand injection of dye
Voiding Voiding cystourethrogramcystourethrogram
USUS
UltrasoundUltrasound
CTCT
VCUGVCUG
Treatment Patent Treatment Patent UrachusUrachus
Patent UrachusPatent Urachus
Urachal CystUrachal Cyst
Usually assx until Usually assx until infectedinfected
Rarely become Rarely become infected in infected in newborn period, newborn period, usu manifests as usu manifests as young adultyoung adult
Infected Urachal cystInfected Urachal cyst
Fever, voiding symptoms, midline Fever, voiding symptoms, midline hypogastric tenderness, mass, UTI hypogastric tenderness, mass, UTI
May drain into bladder or umbilicusMay drain into bladder or umbilicus Rarely can rupture into Rarely can rupture into
preperitoneal tissues or peritoneal preperitoneal tissues or peritoneal cavitycavity
Cultures - Staph AureusCultures - Staph Aureus
USUS
CTCT
Infected Urachal cyst - Infected Urachal cyst - treatmenttreatment
Incision and drainage Incision and drainage Percutaneous drainagePercutaneous drainage Complete surgical excision of Complete surgical excision of
all urachal tissueall urachal tissue 30% recurrence if only drainage30% recurrence if only drainage Staged approach limits amount Staged approach limits amount
of bladder resected of bladder resected
Urachal SinusUrachal Sinus
Becomes Becomes symptomatic symptomatic when infectedwhen infected
Tx – drainage Tx – drainage and resection and resection of urachal of urachal tissuetissue
SinogramSinogram
Urachal DiverticulumUrachal Diverticulum
Blind sac Blind sac at bladder at bladder apexapex
Mostly Mostly assx assx
Urachal DiverticulumUrachal Diverticulum
Vitelline Duct Vitelline Duct AbnormalitiesAbnormalities
Vitelline DuctVitelline Duct
Vitelline Duct is connection Vitelline Duct is connection between midgut and yolk sac between midgut and yolk sac
Usually involutes in 7Usually involutes in 7thth – 9 – 9thth weeks weeks
Vitelline duct Vitelline duct abnormalitiesabnormalities
Meckel’s DiverticulumMeckel’s Diverticulum
Meckel’s DiverticulumMeckel’s Diverticulum
contains ectopic gastric or contains ectopic gastric or pancreatic mucosapancreatic mucosa
In 2% of populationIn 2% of population 2 feet from ileocecal valve, 2 feet from ileocecal valve,
antimesenteric borderantimesenteric border Majority of symptomatic < Majority of symptomatic <
2yrs old2yrs old
PresentationPresentation
Painless GI Bleeding (50%) Painless GI Bleeding (50%) Bowel Obstruction (30%)Bowel Obstruction (30%) Inflammation – Inflammation –
diverticulitis (20%)diverticulitis (20%)
GI BleedingGI Bleeding
Most common cause of Most common cause of bleeding in childrenbleeding in children
Painless, massive, usually Painless, massive, usually self resolvingself resolving
Due to mucosal ulceration Due to mucosal ulceration from acid secretionfrom acid secretion
Meckel’s Scan – GI Meckel’s Scan – GI bleedingbleeding
Bowel ObstructionBowel Obstruction
Due to intussusception, Due to intussusception, diverticulum is the lead pointdiverticulum is the lead point
Sudden severe pain out of Sudden severe pain out of proportion to physical examproportion to physical exam
Hydrostatic Barium enema Hydrostatic Barium enema diagnostic, rarely therapeuticdiagnostic, rarely therapeutic
IntussusceptionIntussusception
IntussusseptionIntussusseption
Meckel’s DiverticulitisMeckel’s Diverticulitis
Sx like appendicitis Sx like appendicitis Result of lumenal obstruction, Result of lumenal obstruction,
bacterial invasion, progressive bacterial invasion, progressive inflammationinflammation
Ectopic gastric mucosa Ectopic gastric mucosa predisposespredisposes
30% incidence of perforations30% incidence of perforations Higher risk of peritonitis Higher risk of peritonitis
TreatmentTreatment
Surgical Resection without Surgical Resection without removal of ileum removal of ileum
V shaped incision at baseV shaped incision at baseresection of involved resection of involved
segment of ileum w/ segment of ileum w/ primary anastamosisprimary anastamosis
Fibrous Vitelline Fibrous Vitelline RemnantRemnant
Fibrous Vitelline Fibrous Vitelline RemnantRemnant
Barium EnemaBarium Enema
Vitelline Umbilical Vitelline Umbilical FistulaFistula
Vitelline Umbilical fistulaVitelline Umbilical fistula
Umbilical polyp Umbilical polyp May drain May drain
enteric enteric contentscontents
Fistulogram Fistulogram shows shows communication communication w/ bowelw/ bowel
HerniationHerniation
Umbilical HerniaUmbilical Hernia
Umbilical herniaUmbilical hernia
ProtrudesProtrudes Rarely incarceratesRarely incarcerates Incidence 10-25% infantsIncidence 10-25% infants 6-10x higher incidence in Black infants6-10x higher incidence in Black infants More in girls, prematureMore in girls, premature Assoc w/ Down’s Synd, Beckwith-Assoc w/ Down’s Synd, Beckwith-
Wiedemann synd, hypothyroidism, Wiedemann synd, hypothyroidism, mucopolysaccharidosismucopolysaccharidosis
TreatmentTreatment
Most close by 3-4 years age Most close by 3-4 years age (>90%)(>90%)
Defect greater than 1.5 – 2 Defect greater than 1.5 – 2 cm less likely to closecm less likely to close
Surgical closure indicated in Surgical closure indicated in kids >5 yearskids >5 years ageage
Proboscoid Umbilical Proboscoid Umbilical HerniasHernias
Proboscoid umbilical Proboscoid umbilical herniashernias
15-20% of umbilical hernias15-20% of umbilical hernias Same sized fascial defectSame sized fascial defect Same likelihood of closing Same likelihood of closing
spontaneouslyspontaneously Excessive redundant umbilical Excessive redundant umbilical
skinskin Surgical repair for social and Surgical repair for social and
cosmetic reasonscosmetic reasons
OmphalitisOmphalitis
OmphalitisOmphalitis
erythema and edema of umbilical erythema and edema of umbilical area area
excellent medium for bacterial excellent medium for bacterial colonizationcolonization
poor hygiene or hospital-acquired poor hygiene or hospital-acquired infectioninfection
Staphylococcus, Streptococcus, Staphylococcus, Streptococcus, Gram (-) rodsGram (-) rods
TreatmentTreatment
IV AntibioticsIV Antibiotics Local cleaning w/ EtohLocal cleaning w/ Etoh Can rapidly progress to Can rapidly progress to
Necrotizing fasciitis (16%) Necrotizing fasciitis (16%) Usually polymicrobialUsually polymicrobial Rapidly fatal (50%)Rapidly fatal (50%) Surgical debridement necessarySurgical debridement necessary
Delayed Cord SeparationDelayed Cord Separation
Separation > 3 wks may be associated Separation > 3 wks may be associated w/ an immune deficiencyw/ an immune deficiency
Normal separation via leukocyte Normal separation via leukocyte infiltration, subsequent necrosisinfiltration, subsequent necrosis
Inherited malfunction of neutrophil, Inherited malfunction of neutrophil, monocyte, or natural killer cellsmonocyte, or natural killer cells
Susceptible to severe bacterial Susceptible to severe bacterial infectionsinfections
Immunologic workupImmunologic workup
Leukocyte Adhesion Leukocyte Adhesion DeficiencyDeficiency
Deficiency of phagocyte surface Ag – Deficiency of phagocyte surface Ag – CR3CR3
Cell surface proteins responsible for Cell surface proteins responsible for phagocyte adhesion to endothelium phagocyte adhesion to endothelium
Inability to egress from circulation to Inability to egress from circulation to areas of inflammation areas of inflammation
Phagocytic activity, degranulaton, and Phagocytic activity, degranulaton, and oxidative metabolism also affectedoxidative metabolism also affected
Thank You!!!Thank You!!!