Differential diagnosis of umbilical polyps and granulomas in children: sonographic and pathologic correlations

A Study of Symptomatic Umbilical Remnants in Children with Evaluation of the Role of Ultrasound as a Diagnostic Modality

Aims

The aim of this study was to study the presentation and management of children with symptomatic "umbilical remnants" (SUmR) and the efficacy of ultrasound (US) in diagnosis and predicting a need for surgery.

Materials and Methods

This study included 65 children aged 2 months-12 years with clinical findings suggestive of umbilical remnants (UmR): umbilical granuloma (UG); umbilical polyp or prolapsing mucosa, periumbilical inflammation/mass, or persistent umbilical discharge. Investigations included US and bacteriological culture-sensitivity tests of umbilical discharge. UG and umbilical polyps were excised. Minilaparotomy was performed for other SUmR and UG/umbilical polyps where US suggested intra-abdominal pathology. The excised UmR tissue underwent histopathologic examination (HPE) for final diagnosis.

Results

There were 40 males and 25 females, with a median age of 6 months. The three groups after final diagnosis were (i) UG (n = 38), (ii) vitellointestinal (VI) remnants (n = 21), umbilical polyp (n = 17), patent VI duct (PVID) (n = 3), and umbilical cyst (n = 1), and (iii) urachal remnants (UR) (n = 6), urachal cysts (n = 3) and patent urachus (n = 3). Forty-nine UG/umbilical polyps underwent simple excision. Sixteen (24.6%) patients underwent minilaparotomy, and in seven, US findings correlated with operative findings. US was false positive for intra-abdominal pathology in six cases (UG = 3; umbilical polyp = 3) and false negative in PVID (n = 3). UG and umbilical polyps were differentiated only by HPE. There were no complications or recurrence. On grouping by presentation, US as a diagnostic modality in UG/umbilical polyp had a specificity of 85% with a diagnostic accuracy of 89.09%. In UR, the figures were sensitivity 100%, specificity 0%, positive predictive value (PPV) 100%, negative predictive value (NPV) 0%, and diagnostic accuracy 100%. For VID remnants excluding umbilical polyps, the sensitivity was 25%, specificity 0%, PPV 100%, NPV 0%, and diagnostic accuracy 25%. Overall, the sensitivity of abdominopelvic US as a diagnostic modality in SUmR was 70%, specificity 89%, PPV 53%, and NPV 94% with overall diagnostic accuracy of 84%.

Conclusions

SUmR is most commonly UG or umbilical polyp and could not be differentiated on clinical grounds alone. In suspected urachal anomalies/UR, US is an effective diagnostic modality. Overall, however, US has relatively low sensitivity and a low PPV and should be regarded as an accessory rather than a very effective diagnostic modality in SUmR. One-stage excision of SUmR is safe and effective. HPE of the excised SUmR is essential for the final diagnosis.

Standardization of the Umbilical Scarectomy and Exploratory Laparotomy for Umbilical Mucosal Polyps

Background Umbilical mucosal polyps are common, but physicians' unfamiliarity with them can prolong the patient's illness. Furthermore, the details of surgery for umbilical mucosal polyp removal are not well documented. Methods Patients with an umbilical mucosal polyp diagnosed on the basis of the lesion's characteristic appearance were prospectively enrolled. The surgery involved an umbilical scarectomy with the removal of a minimum of the surrounding skin and an exploratory laparotomy to detect any lesions extending into the peritoneal cavity. Results Fourteen patients with a median duration of illness of ten months (range: one month to seven years) were enrolled, and 13 (92.9%) received surgery while one patient whose symptoms resolved following topical steroid treatment did not. Inspection of the intestinal mucosa of all the patients found lesions deep within the umbilicus in four (30.8%) of the 13 surgical patients, including an omphalomesenteric band, umbilical cyst, and umbilical sinus with gastric mucosa in one, one, and two patients, respectively. The postoperative course was uneventful except for one patient who had temporary granulation. Conclusions Umbilical mucosal polyps can be readily diagnosed by their characteristic appearance, thereby preventing the prolongation of illness. An umbilical scarectomy and abdominal exploration may be useful for preventing recurrences and intestinal obstruction.

Common Salt versus Silver Nitrate for the Treatment of Umbilical Granuloma in Infants: An Open-label, Single-center, Pilot Randomized Controlled Trial

Aim

This study aims to compare the efficacy and safety of topical application of common salt (CS) in comparison to silver nitrate (SN) for treating infants with umbilical granuloma (UG).

Materials and Methods

We conducted an open-label, prospective, single-center, pilot randomized controlled trial. Thirty-seven infants with a clinical UG diagnosis were enrolled between October 2022 and July 2023, excluding those previously treated for UG. Patients were randomly assigned (using the Randomizer® app) to receive either topical CS (applied thrice daily by caregivers at home for 5 days) or SN (applied by pediatric surgeon in clinic and kept under occlusive dressing for 48 h). Patients with partial/no healing received an additional session of the same treatment. Nonresponders transitioned from CS to SN, and vice versa, for two more applications. Healing rates were compared with a significance level of α =0.05.

Results

Out of 34 patients (18 CS and 16 SN), 32 successfully completed the trial (17 CS and 15 SN). No significant differences were observed in baseline characteristics. Efficacy rates of CS (19/22; 86.36%) and SN (11/17; 64.71%) did not significantly differ (P = 0.056; 95% confidence interval [CI] -0.4832-0.0502). No major adverse events were reported. CS showed superior healing outcomes in infants below 3 months of age (19/22; 86.36%) compared to SN (11/17; 64.71%) (P = 0.056; 95% CI - 0.4832-0.0502). The timing of umbilical cord detachment did not significantly affect healing rates.

Conclusion

Widespread availability, ease of access, suitability for safe home application, and cost-effectiveness make CS a primary treatment option for UG. Larger patient cohorts are needed for conclusive results.

Umbilical Granuloma: Frequency, Associated Factors, 10-Year Treatment Trends, and Effectiveness at a Single Hospital in Japan

Umbilical granuloma (UG) is a common problem during the neonatal period; however, its epidemiology and etiology are poorly studied, and the best treatment option has not yet been established. We examined the medical records of neonates who were born and underwent 1-month evaluations at our hospital between 2013 and 2022 to investigate the frequency of-and factors associated with-UG, as well as the annual trends of UG treatments and their efficacy. Of the 6680 eligible neonates, 395 (5.9%) had UG. The annual incidence rate ranged from 3.8% to 7.3%. Gestational age, birth weight, and incidence of meconium-stained amniotic fluid were significantly associated with UG. Silver nitrate cauterization was the predominant UG treatment from 2013 to 2016. Silver nitrate cauterization and topical betamethasone valerate were nearly equally applied in 2017. Betamethasone application became predominant in 2018. The healing rates during the initial treatment period were 91% for silver nitrate cauterization, 97.7% for betamethasone application, 60% for ethanol disinfection, and 88% for ligation; these rates were significantly different (p < 0.001). Topical steroid application may be the most effective treatment. If steroid application is ineffective, then silver nitrate cauterization and ligation may be important treatment options.

Ultrasound findings of distal umbilical artery calcification: A case report

Umbilical artery calcification is a rare finding with only a small number of cases reported on radiographs. To date, no cases have been described on ultrasound. Reported cases were limited to the horizontal segment of the medial umbilical ligament. This case report presents a unique case of ultrasound findings of bilateral umbilical artery calcification within the vertical (distal) segment of the medial umbilical ligament.

Omphalomesenteric Duct Anomalies in Children: A Multimodality Overview

The omphalomesenteric duct is an embryologic structure that connects the yolk sac with the primitive midgut of the developing fetus. Omphalomesenteric duct anomalies include a group of entities that result from failed resorption of the omphalomesenteric duct. These anomalies include Meckel diverticulum, omphalomesenteric fistula, fibrous bands, cysts, and umbilical polyps. Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract and is usually asymptomatic. Symptoms develop when Meckel diverticulum involves complications such as hemorrhage, inflammation, and perforation, or when it causes intussusception or bowel obstruction. Hemorrhage is the most common complication of Meckel diverticulum, and technetium 99m-pertechnetate scintigraphy is the imaging modality of choice for detecting acute bleeding. US and CT are commonly used for the evaluation of patients with other complications such as obstruction and inflammation. Nevertheless, the diagnosis of these complications can be challenging, as their clinical manifestations are usually nonspecific and can masquerade as other acute intraabdominal entities such as appendicitis, inflammatory bowel disease, or other causes of bowel obstruction. There are other umbilical disorders, such as urachal remnants and umbilical granuloma, that may present with symptoms and imaging findings similar to those of omphalomesenteric duct anomalies. An accurate preoperative diagnosis of omphalomesenteric duct anomaly is crucial for appropriate management and a better outcome, particularly when these anomalies manifest as a life-threatening condition. The authors review the anatomy, clinical features, and complications of omphalomesenteric duct anomalies in children, describing the relevant differential diagnoses and associated imaging findings seen with different imaging modalities. ^©RSNA, 2021.