Gill-Appiott, Frances T. MSN, RN, CPNP AC/PC
Frances T. Gill-Appiott, MSN, RN, CPNP AC/PC Pediatric Nurse Practitioner General Surgery/Trauma, DuPont Hospital for Children, Wilmington, DE.
The author declares no conflict of interest.
The case presented highlights of a 3-week-old infant who arrived in the emergency department (ED) with an umbilical mass. He had been evaluated by the pediatrician, and the parents were reassured that this was a normal finding of an umbilical granuloma. After treatment with silver nitrate, the mass persisted. The family was referred to the ED for further evaluation and treatment.
NV was a 3-week-old male infant that presented to the ED with a chief complaint of an umbilical mass. The parents reported that he was the product of a full-term pregnancy G III, P III AB 0 healthy mother. He weighed 2.5 kg and had a normal newborn course. He was discharged on his second day of life. Shortly after arriving at home, he was noted to have “yellow drainage” at the base of the umbilical cord, which was treated locally with alcohol with each diaper change. The drainage persisted and frequently soaked the clothing that he was wearing. On day of life 18, the cord fell off. Both parents noted that “it didn’t look the same as our other two children” and described the umbilical area as “swollen red tissue with a lot of yellow drainage.” They sought medical attention, and NV was evaluated by the pediatrician. The parents were reassured that this was a common finding of umbilical granulation tissue and it would recede spontaneously. No specific treatment was ordered. When the tissue at the umbilical area did not change and the drainage persisted, they returned to the pediatrician and were referred to the emergency ED for evaluation. Upon arrival, the ED attending evaluated NV, obtained an ultrasound, and placed a surgical consult. The surgical resident examined the child and felt that the umbilical mass represented an umbilical granuloma. The suggested treatment was the application of silver nitrate to the tissue. Discharge to home and follow up with the pediatrician within 3 days. The ED attending was not comfortable with this plan and placed a call to the nurse practitioner for a second opinion.
The patient was a healthy-appearing newborn infant in no apparent distress. Mother stated that he had been tolerating breast milk feedings well and urinating/stooling normally. He had no history of fever. Data from the ED are as follows: temperature of 36.6°C, heart rate of 162 beats per minute, respiratory rate of 44 breaths per minute, and oxygen saturation of 100%. Capillary refill was brisk at less than 2 seconds. The weight was 2.82 kg. The abdomen was soft, nondistended, and without hepatosplenomegaly. The umbilical stump revealed a 1-cm palpable umbilical defect that had a 2 mm × 1 mm protuberant erythematous tubular structure with a sinus tract evident (Figure 1). A scant amount of clear/yellow thin fluid was noted at the base of the umbilicus. There was no active drainage from the apparent sinus tract. The penis was circumcised, and the urinary meatus appeared normal. The testicles were well descended in the scrotum and were normal in size, shape, and position.
The official reading did not reveal bowel loops in the umbilicus, and there was no fluid collection. On color flow, the vessels were patent in the umbilicus. Grayscale and scanning was performed through the urinary bladder, and no evidence of deeper abdominal involvement or a patent urachus was noted. The surgery team was called to discuss the results of the study and the patient and the plan admission to the general surgical service.
Based on the history and physical examination, the diagnosis was consistent with omphalomesenteric duct (OMD) remnant.
NV was taken to the OR, and the sinus tract was probed with an 18-gauge angiocatheter. This passed easily through the tract, and 3 ml of sterile water easily passed through the structure without backflow. The 1-cm umbilical defect was bluntly dissected, and a 3-cm bowel-like structure, which was fed by a single vessel, was identified. As the structure was gently delivered to the operative field, it was noted to be attached to a loop of bowel at the antimesenteric border. Overall, these findings were consistent with an OMD remnant with a sinus tract draining through the umbilical defect. The vessels were divided, and a wedge of tissue was excised from the loop of intestine at the antimesenteric border, including the remnant. The specimen was sent to pathology (Figure 2).
The specimen was described as a soft, smooth-to-shaggy tan-pink tubular structure measuring 2.8 cm in length and varying from 0.7 to 1.0 cm in diameter at opposite ends. Microscopic evaluation confirmed the diagnosis of OMD remnant. There was a focus of gastric mucosal epithelium with areas of mucosal erosion, fibrin, and granulation tissue with subadjacent mural fibrosis and inflammation compatible with the documented clinical impression (Figures 3 and 4).
The OMD, also known as the vitelline duct, is the remnant of the connection between the embryonic midgut and the yolk sac, which provides nutrition to the developing embryo until the placenta is established (Walji-Virani & Russo, 2011). This temporary structure of fetal development normally involutes by 8–9 weeks of gestation (Kondrich, Woo, Ginsberg, & Levin, 2012). This remnant is one of the rare congenital anomalies associated with the primitive yolk stalk (Pauleau, Commandeur, Andro, & Chapelliler, 2012). If the involution is incomplete, there are multiple malformations that can occur including fistulas, sinus tracts, cysts, polyps, congenital bands, and most commonly Meckel’s diverticulum (Durakbasa et al., 2010). The differential diagnosis related to umbilical drainage should include a patent urachus. This is a connection between the fetal bladder and the allantois. When the bladder descends into the pelvis, the urachus is stretched and obliterates, resulting in a fibrous cord running from the umbilicus to the dome of the bladder (Naiditch, Radhakrishnan, & Chin, 2013).
Most patients with OMD remnants remain asymptomatic, and many of these abnormalities are incidental findings during other abdominal operations (Durakbasa et al., 2010). Symptomatic lesions may present with painless rectal bleeding, abdominal pain, distention, nausea, and vomiting. A devastating complication of an OMD that is not patent occurs when the fibrous bands that attach to the anterior abdominal wall creates a small bowel obstruction or volvulus (Kondrich et al., 2012).
In this case, a urachal remnant was ruled out by ultrasound evaluation. The pathology report supported the diagnosis of OMD remnant by identification of ectopic gastric tissue. The literature denotes that the presence of ectopic, pancreatic, or gastric tissue in the specimen is a common occurrence (Durabasa et al., 2010).
NV tolerated the surgery well and was discharged on the third postoperative day.
Durakbasa C. A., Okur H., Mutus H. M., Bas A., Ozen M. A., Sehiralti V., Zemheri I. E. (2010). Symptomatic omphalomesenteric duct remnants in children. Pediatrics International, 52, 480–484. doi:10.1111/J.1442-200x.2009.02980.x
Kondrich J., Woo T., Ginsburg H. B., Levine D. A. ( 2012). Evisceration of small bowel after cauterization of an umbilical mass. Pediatrics, 130( 6), 1708–1710. doi:10.1542/peds.2012-0623
Pauleau G., Commandeur D., Andro C., Chapellier X. ( 2012). Intestinal prolapse through a persistent omphalomesenteric duct causing small bowel obstruction. South African Journal of Surgery, 50( 3), 102–103. doi:7196/SAJS.1289
Walji-Virani S., Russo M. A. (2011). An infant with yellow umbilical drainage. Gastroenterology, 140( 7), e5–e6. doi:ID.1053/J.Gastro.2010.03.082