THE UMBILICUS

The most common abnormality of the

umbilicus is an umbilical hernia, described
above.
The important congenital abnormalities of
the umbilicus are exomphalos and fitula,
and the
common acquired conditions (apart from
hernias)
are inflmmation and invasion by tumour.

Exomphalos (Fig. 14.19)

This condition, present at birth, represents
an
intrauterine failure of the intestines to
return to the
abdomen, combined with a failure of the
two sides
of the laterally developing abdominal wall
to unite
to cover the embryonic defect.
All layers of the abdominal wall are
defiient over
the protruding intestines. Their only
covering is a thin,
transparent membrane formed from the
remnant of
the coverings of the yolk sac. Once this
membrane
is exposed to the air, it loses its thin,
transparent
appearance, becoming thicker and
covered with an
opaque, firinous exudate. Urgent surgery
is required.

Umbilical fitulas
Four structures pass through the umbilicus
during
fetal development: the umbilical vein, the
umbilical
arteries, the vitello-intestinal duct and the
urachus.
If either of the last two tubes fails to close
properly,
there will be an intestinal or a urinary
fitula.
A patent vitello-intestinal duct (Fig. 14.20)
in the
neonate produces an intermittent
discharge of
mucus and sometimes faeces from the
umbilicus. Itis a rare abnormality.

Sometimes there is visible small

intestinal mucosa lining an obvious fitula,
but on
other occasions there may only be a small
flid leak
and the condition mimics an umbilical
granuloma.
The duct connects to the ileum at the site
of a
Meckels diverticulum.
A patent urachus can become a track
through
which urine can leak onto the external
surface
of the abdomen through the umbilicus.
This rare
condition occasionally presents in
childhood, but
more commonly in adult life in association
with
chronic retention of urine caused by
disease of the
prostate.
The patient complains of a watery
discharge from
the umbilicus.
An umbilical discharge is nearly always
caused by
infection in the umbilicus; nevertheless,
remember
the possibility of a urachal fitula,
particularly if there
are symptoms of urinary obstruction or a
palpable
bladder.
Both these embryonic tracts may partially
close,
leaving a patent segment that becomes a
cyst
(Fig. 14.21).
A vitello-intestinal duct cyst is a small,
spherical,
mobile swelling deep to the umbilicus that
is
tethered to the umbilicus and to the small
bowel by
a firous cord.
A urachal cyst is an immobile swelling
below the
umbilicus deep to the abdominal muscles.
It may
become large enough to flctuate and have

a flid
thrill. If it is still connected to the bladder,
it may
vary in size and be diffiult to distinguish
from a
chronically distended bladder.

Umbilical adenoma
An umbilical adenoma is a patch of
intestinal
epithelium left behind when the vitellointestinal
duct closes. It may produce a discharge
from the
depths of the umbilicus, but more often
protrudes
from the umbilicus and looks like a
raspberry.
Although it resembles an umbilical
granuloma,
the cause is quite different. It will not
resolve
spontaneously.
The mother complains that the baby has a
lump
at the umbilicus and a mucous discharge.

around
the umbilicus is red and tender, and
exuding a
seropurulent discharge with a
characteristic foul smell.
The whole umbilicus may feel indurated,
especially if there is an ompholith or a
tumour deposit.
Although simple dermatitis or skin
infection is
by far the most common cause of a
discharge from
the umbilicus, it is essential to exclude the
other
causes of an umbilical discharge, which
are listed in
Revision panel 14.7.
True omphalitis is infection of the stump of
the
umbilical cord following inadequate
postnatal care
and cleanliness.

Omphalitis
Infection within the umbilicus is not
uncommon
in adults (Fig. 14.23). It is usually
associated with
inadequate hygiene and a sunken
umbilicus
caused by obesity, made worse by any
coexisting
paraumbilical hernia. The condition is
similar to
the intertrigo that occurs between folds of
skin
elsewhere associated with obesity and
sweating,
which become secondarily infected with
skin
organisms that produce an unpleasant
smell.
The patient complains of umbilical
discharge,
pain and soreness.
On examination, the skin within and

Ompholith
When the sebaceous secretions that
accumulate
in the umbilicus are mixed with the broken
hairs
and flff from clothing that become sucked
into
the umbilicus, the mixture can form a fim
lump,
worthy of the name umbilical stone or

ompholith.
The outside tip of the concretions dries out
and may
protrude like a sebaceous horn. In certain
parts of
the UK, there is an old wives tale that if
this stone is
removed, the sufferer will bleed to death!
Routine personal hygiene will usually
prevent
the formation of an ompholith, but this is
not always
as simple as it sounds, as the umbilicus
can be deep
and narrow, particularly in the obese.
Small concretions are common and
uncomplicated.
An abscess will occasionally develop in a
narrownecked umbilicus containing an
ompholith. The
patient feels unwell and has a very
painful, throbbing,
swollen umbilicus that may be diffiult to
distinguish
from a strangulated umbilical hernia.
Pus tracking from an intra-abdominal
abscess
may occasionally point at the umbilicus,
the most
common cause being diverticular disease.

Secondary carcinoma
(Sister Josephs nodule)
A fim or hard nodule bulging into the
umbilicus,
underneath the skin or eroding through it,
in a patient
who is losing weight and looks unwell is
likely tobe a nodule of metastatic cancer
(Fig. 14.24). This
presentation always indicates advanced,
widespread
intra-abdominal disease, and the primary
tumour is
usually in the abdomen.
The tumour cells reach the umbilicus via
lymphatics that run in the edge of the
falciform
ligament alongside the obliterated
umbilical vein, or
by transperitoneal spread.
Nodules of secondary carcinoma may

ulcerate,
bleed and become infected. Rarely, the
tumour
deposit is in continuity with bowel and
there may be
an acquired intestinal fistula.

Endometrioma
If, in a female patient, the umbilicus
enlarges,
becomes painful and discharges blood
during
menstruation, it may contain a patch of
ectopic
endometrial tissue.

Discolouration of the umbilicus

The following physical signs are rare, but
the diseases
that cause them are common and serious.
A blue tinge around the umbilicus, caused
by
dilated, tortuous, sometimes visible, veins,
is called
a caput medusae, after Medusa, the
mythical Gorgon
who had small snakes on her scalp instead
of hair.
The dilated veins are collateral vessels
that have
developed to circumvent portal vein
obstruction.
There will be other signs of portal
hypertension and
liver failure.
Yellow-blue bruising around the umbilicus
(Cullens sign) and in the flnk (Grey
Turners sign; see
Chapter 15) may be caused by pancreatic
enzymes
that have tracked along the falciform
ligament to
the umbilicus or across the retroperitoneal
space
to the loin and digested the subcutaneous
tissues
following an attack of severe acute
pancreatitis. Both
appear a few days after the beginning of
the acute
symptoms.
Bruising at the umbilicus can also be

associated
with intra-abdominal bleeding, particularly
when
it is extraperitoneal. Causes include
ruptured

aortic aneurysms, ruptured ectopic

pregnancy and
accidental periuterine bleeding in
pregnancy