Thomas V. Mincheff, General Surgeon, Department of Surgery, Carolina Pines Regional Medical Center, Hartsville, SC
Thomas V. Mincheff, MD
Department of Surgery
Carolina Pines Regional Medical Center
Persistent drainage from the umbilicus is observed most often in pediatric patients and is usually associated with omphalitis, urachal duct cysts, omphalomesenteric duct remnants, or umbilical granulomas. This report describes an unusual case of abnormal serous drainage from the umbilicus of an adult who was later found to have a foreign body imbedded deep in the umbilical canal. The patient had no apparent history of trauma, and a review of the literature yielded no similar cases.
A 29-year-old, obese, mildly retarded black man was referred for evaluation and treatment of a chronically draining umbilicus, which was thought initially to result from poor hygiene due to his obesity. On physical examination, the umbilicus appeared normal externally. Insertion of the index %uFB01nger into the deep canal did not reveal any masses or foreign material. There were no signs of infection, and the patient never reported any pain or tenderness. Because there were no obvious external signs of abnormality except for the nonodorous umbilical discharge, a computed tomography (CT) scan of his abdomen was obtained. This revealed an unusual metallic object imbedded deep in the umbilical canal, well below the skin (Figure 1). Both the patient and his father, who had accompanied him to the appointment, denied any history of trauma and were bewildered by the %uFB01ndings.
The patient subsequently underwent surgery for removal of the unknown foreign body. A vertical incision was made through the midportion of the umbilicus. The skin edges were grasped with Allis clamps, and the umbilicus was everted. The foreign body was found nearly 2 cm below the skin surface. Intraoperative and postoperative %uFB01ndings identi%uFB01ed a 5-cm coil of wire, similar to what one would %uFB01nd on a spiral-bound notebook, lodged deep in the umbilical canal and surrounded by a thick layer of granulation tissue (Figure 2). After removal of the foreign body, the umbilicus was reconstructed. The patient's recovery was uneventful, and a postoperative small bowel follow through con%uFB01rmed that there was no communication between the small intestine and the umbilicus.
A literature review found very little on the subject of foreign bodies in the umbilicus. Self-in%uFB02icted injuries are uncommon and are usually limited to super%uFB01cial skin injuries. In 1985, however, Watson reported the case of a 22-year-old man with a severe personality disorder who pushed two ballpoint pens deep into the skin by his umbilicus, creating an opening into the abdominal cavity through which he then inserted matches.1 No similar cases have been reported.
With respect to the mildly retarded patient in this report, the only obvious explanation on how the wire coil became imbedded deep within his umbilicus is through self-in%uFB02iction or because another individual pushed it in there sometime in the patient's past. The CT scan and the postoperative small bowel follow through ruled out any communication between the umbilicus and the gastrointestinal tract; thus, this was not a possible pathway for the unusual foreign body.
Persistent drainage from the umbilicus is usually associated with omphalitis, urachal cysts, omphalomesenteric duct remnants, or umbilical granulomas. Retained polyethylene umbilical artery catheters acting as a foreign body also have been noted in the literature to cause chronic drainage from the umbilicus.2,3 The most common cause of umbilical drainage is an umbilical granuloma. Failure of the vitelline duct, allantois, or the umbilical vessels to undergo full normal involution results in persistent remnants of these structures.4 A mild infection probably plays a role in the development of some cases of umbilical granulomata, which usually are treated with topical silver nitrate or diathermy.5 Ultrasonography may be helpful in ruling out the presence of an associated intraperitoneal sinus or tract.4 Fistulography has been used to assess an umbilical sinus, but this may be unreliable in demonstrating the sinus tract and any communicating cysts.4
The differential diagnosis of an umbilical granuloma should include a patent urachus, persistent vitelline duct, and an umbilical polyp, all of which require surgical treatment and management.5 The patient had no history of discharging urine or feces through a cutaneous opening, which excluded the diagnosis of a patent urachus or patent vitelline duct. A postoperative small bowel follow through conclusively ruled out this rare possibility. A patent vitelline duct may cause an in%uFB02amed umbilicus, but more commonly presents as an umbilical polyp in later life.6 Patients who present with an umbilical granuloma should be evaluated for granuloma pyogenicum and umbilical talc granuloma, both of which have different histologic appearances and characteristics.5
Abnormal drainage from the umbilicus in an obese adult should not automatically be attributed to poor hygiene, and other causes must be given serious consideration. A CT scan of the abdomen was obtained in this case because the patient had no obvious external signs of abnormality, except for the nonodorous umbilical discharge. An unusual foreign body was found imbedded deep in the abdominal wall, at the level of the umbilicus. In a mildly retarded individual, self-in%uFB02iction should be considered as a possible cause, particularly if there is no history of trauma. Although abnormal drainage or discharge from the umbilicus is rare in adults, a patent urachus, vitelline duct, umbilical polyp, umbilical granuloma, or retained umbilical artery catheter should not be discounted when making a differential diagnosis.