Radiology Casebook

Pratibha A. Ankola, MD
Gunjan Pradhan, MD
CASE REPORT
A 1705-gm infant boy was born at 36 weeks gestation to a
39-year-old gravida 4 para 4 mother by precipitous vaginal deliv-
ery with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively.
Maternal antenatal data showed normal serum-fetoprotein and
chromosome analysis. Physical examination revealed a symmetri-
cal small for gestational age male newborn with no abnormalities.
Blood glucose was low on initial monitoring, and the infant
needed orogastric feeding for the first few days. On day 9 after
birth, the baby developed purulent discharge from the umbilical
stump with periumbilical erythema. Omphalitis was suspected,
and the baby was started on broad-spectrum antibiotics after com-
plete evaluation for sepsis. The umbilical discharge persisted the
next day and was feculent with some bleeding. Radiographic study
was done to establish a definitive diagnosis (Figure 1). Diagnosis
was confirmed at surgery as shown in Figure 2. Surgical excision
with repair of the intestine and umbilicus was done by pediatric
surgery. The infants postoperative course was uneventful, and he
was discharged from the hospital subsequently tolerating full oral
feedings.
DENOUEMENT AND DISCUSSION
Patent Omphalomesenteric Duct
The omphalomesenteric duct is formed between weeks 5 and 9 of
gestation and connects the developing embryonic midgut to the
yolk sac.
1
It usually involutes by week 12 of gestation
2
; incomplete
regression may occur in 2% of live-born infants,
3
resulting in
various lesions including Meckels diverticulum, umbilical fistula,
polyps or cysts, omphalomesenteric cysts, and patent ompha-
lomesenteric duct.
Clinical manifestations
The presence of serous, sero-purulent, bilious, or feculent umbili-
cal discharge is suggestive of a patent omphalomesenteric duct
with umbilical fistula.
5
In some cases, the patent duct may appear
similar to umbilical granuloma or may present with small bowel
prolapse due to intussusception.
6
In 217 children with ompha-
lomesenteric duct remnants, 40% were symptomatic.
2
There is a high
male predominance in symptomatic cases. The most common symp-
tomatic form of omphalomesenteric duct remnants is Meckels diver-
ticulum
2
, which presents with rectal bleeding (58%), intestinal ob-
struction due to volvulus (33%), or intussusception and diverticulitis.
Additional congenital anomalies associated with omphalomesenteric
duct malformation include cardiac defects, esophageal atresia, ileal
atresia, and Downs syndrome.
Diagnosis
The diagnosis of patent omphalomesenteric duct with umbilical fis-
tula can be made by cannulating the discharging lumen and inject-
ing contrast material. The contrast material entering the small bowel
(Figure 1) confirms the diagnosis.
Metropolitan Hospital Center, New York Medical College, New York, NY.
Address correspondence and reprint requests to Pratibha A. Ankola, MD, Department of Pe-
diatrics, Room 523, Metropolitan Hospital Center, 1901 First Avenue, New York, NY 10029.
Figure 1. Fistulogram obtained by injecting Hypaque 60 with a feeding tube
through the umbilical opening. The fistulogram shows contrast in ileal loops, con-
firming patent omphalomesenteric duct.
Journal of Perinatology 2000; 3:196 197
2000 Nature America Inc. All rights reserved. 07438346/00 $15
196 www.nature.com/jp
Perinatal/Neonatal
Casebook

Management
Patent omphalomesenteric duct with umbilical fistula requires surgi-
cal resection to prevent possible complications including infection,
intestinal prolapse, and intestinal bleeding.
References
1. Sadler TW. Langmans Medical Embryology. 5th ed. Baltimore, MD: Williams &
Wilkins; 1985. p. 71.
2. Vane DW, West KW, Grosfeld JL. Vitelline duct anomalies: experience with 217
childhood cases. Arch Surg 1987;122:5427.
3. Shaw A. Disorders of the umbilicus. In: Welch KJ, Randolph JG, Ravitch MM,
et al, editors. Pediatric Surgery. 4th ed. Chicago, IL: Year Book Medical Publish-
ers; 1986. p. 7319.
4. McCalla CO, Lajinian S, DeSouza D, Rottein S. Natural history of antenatal
omphalomesenteric duct cyst. J Ultrasound Med 1995;14:639 40.
5. Kami Y, Zaki AM, Honna T, Tschida Y. Spontaneous regression of patent ompha-
lomesenteric duct: from fistula to Meckels diverticulum. J Pediatr Surg 1992;27:
1156.
6. Moore TC. Omphalomesenteric duct malformations. Semin Pediatr Surg 1996;5:
116 23.
Figure 2. Patent omphalomesenteric duct with the bowel loop connection at
surgery.
Journal of Perinatology 2000; 3:196 197 197
Radiology Casebook Ankola and Pradhan