Chapter 10. Surgery and Genitourinary

Clinical Summary

Intussusception is when the proximal portion of the intestine invaginates into the distal portion, causing an obstruction. Early in the process, lymphatic return is impeded, then as the edema and pressure increase, venous and arterial flow is compromised. Infarction of the collapsed bowel segment may occur. Intussusception usually occurs at age 3 months to 3 years, with a peak in infants <1 year old. In children <3 years old, it is generally idiopathic and possibly due to prominent lymphoid tissue in the intestine serving as a lead point. The majority are ileocolic, although may present anywhere along the lower gastrointestinal tract. In older patients, lead points include Meckel diverticula, polyp, tumor (lymphoma or hemangioma) or intramural edema and hematoma from Henoch-Schönlein purpura. Sites other than ileocolic are also associated with underlying pathology.

Patients typically present with sudden-onset, severe, colicky abdominal pain at regular intervals and vomiting (initially nonbilious; may progress to bilious), bloody stool (“current jelly”—with mucus and gross blood or occult blood), and a “sausage-like” abdominal mass. Patients often curl up to guard the abdomen. Typically patients present without some, not all of the above, symptoms and they may be perfectly well between episodes. Lethargy and irritability may be prominent. The physical exam may show a “Dance sign” or an “empty right lower quadrant.”

The differential diagnosis includes gastroenteritis, constipation, volvulus, toxin ingestion, or encephalopathy and any other condition that produces GI obstruction.

Emergency Department Treatment and Disposition

Obtain abdominal radiographs (supine, prone, and left lateral decubitus) for screening and to exclude free air. Obtain ultrasound for definitive diagnosis. Order complete blood count (CBC), serum electrolytes, blood type and screen, and consult surgery. Provide IV hydration and keep patients NPO (nothing by mouth). Attempt reduction of intussusceptions involving the colon with hydrostatic enema (air, barium, water). If reduction is not achieved after 3 attempts, consider repeated delayed reduction, or refer the child for operative reduction. Ileoileal intussusceptions either spontaneously reduce or require operative reduction. Free air on the radiograph or peritonitis is indication for immediate operative reduction. Whether or not to admit patients after successful reduction is controversial because of the potential for early recurrence.

Pearls

1. Intussusception is often misdiagnosed as gastroenteritis.

2. Profound lethargy may be the only symptom of intussusception and patients often get misdiagnosed as septic or in a postictal state, delaying diagnosis.

3. Perform a rectal exam for occult blood in all suspected cases of intussusception (50%–75% positive).

4. Evaluate for a pathologic lead point in patients > 3 years old.

The authors acknowledge the special contributions of Binita R. Shah, MD, to prior edition.

Clinical Summary

Pyloric stenosis is the idiopathic hypertrophy of the pylorus muscles, which creates a gastric outlet obstruction. Generally occurring in infants between the second week and second month of life (or later in preterms), it occurs more frequently in first-born boys, with a male-female ratio of about 4:1.

Infants present as otherwise well, but with increasing nonbilious vomiting (often described as projectile) soon after feeding. The patient is hungry right after vomiting. The history often includes “constipation” or a decrease in the number of stools. After several days of vomiting, dehydration and weight loss may occur. Vigorous vomiting may cause a Mallory-Weiss tear that presents with coffee-ground emesis.

Physical exam may reveal an “olive” (a firm, ballotable mass with size and shape of an olive) in the mid-epigastrum as well as a visible peristaltic wave. With delayed presentation, cachexia may be present. The differential diagnosis includes gastroesophageal reflux, overfeeding, gastroenteritis, inborn errors of metabolism, adrenal insufficiency and other high-grade obstructions.

Emergency Department Treatment and Disposition

Order serum electrolytes, which commonly reveals hypochloremic hypokalemic metabolic alkalosis. Other findings include acidic urine pH (paradoxical aciduria in the face of metabolic alkalosis) and mild hyperbilirubinemia. Order ultrasound to confirm diagnosis, and consider an upper gastrointestinal (GI) study if the ultrasound is inconclusive. Correct dehydration and electrolyte abnormalities, which must be done prior to pyloromyotomy. Place a nasogastric tube for continued vomiting. Consult surgery and admit patient for intravenous (IV) hydration and pyloromyotomy. Most patients will tolerate feeds and be discharged home within 48 hours of surgery.

Pearls

1. Pyloric stenosis is the most common cause of hypochloremic metabolic alkalosis in infancy.

2. The best time to examine for an “olive” is soon after the infant has vomited.

3. Pyloric stenosis is not a surgical emergency but may be a medical emergency because of electrolyte disturbances and dehydration. Most patients will require rehydration for 24 to 48 hours prior to surgery.

Clinical Summary

Acute nonperforated appendicitis is most commonly seen in school-aged children and teens. It is extremely difficult to diagnose in these preschoolers, and is often perforated at presentation in these young children. Patients classically present with periumbilical pain migrating to the right lower quadrant, fever, anorexia, vomiting, localized peritonitis, and/or guarding. Localization of pain and accompanying complaints vary with the length and position of the appendix, which is highly variable. For example, a retrocecal appendix is likely to cause rectal irritation and diarrhea, whereas an appendix abutting the bladder may cause dysuria, and one that abuts the liver may cause pain in the right upper quadrant.

Various “signs” are used to describe the classic findings. These are also variable depending on the position of the appendix, including McBurney point tenderness: tenderness one-third the distance from the right anterior superior iliac spine to the umbilicus; Rovsing sign: pain felt in the right lower quadrant with palpation of the left lower quadrant; Psoas sign: pain with extension of the right hip due to an inflamed appendix adjacent to the psoas muscle; and Obturator sign: pain with passive internal rotation of the flexed right hip. Differential diagnoses include lower lobe pneumonia, genitourinary pathologies (eg, testicular torsion, pyelonephritis), ovarian pathologies (eg, ovarian torsion, mittelschmerz), ectopic pregnancy, pelvic inflammatory disease, and other surgical pathologies (eg, intussusception, midgut volvulus).

Emergency Department Treatment and Disposition

Appendicitis is a clinical diagnosis that does not require routine imaging. If diagnosis is uncertain, order ultrasound or computed tomographic (CT) scan, noting that neither is 100% sensitive or specific. Obtain laboratory tests including CBC with differential, electrolytes including glucose, C-reactive protein, pregnancy test (adolescent females), and urinalysis—all of which may facilitate diagnosis, though no laboratory value alone is diagnostic. Provide IV hydration as needed and keep patients NPO. Provide adequate analgesia, including morphine as needed (does not mask symptoms). Consult surgery and consider admission for serial abdominal exams if diagnosis is unclear. Provide antibiotics (coverage for gram-negative and anaerobic bacteria) after the diagnosis is made and in consultation with surgery.

Pearls

1. Rectal exam may be useful in localizing the pain of a retrocecal appendix.

2. Ability to hop up and down on the right leg without pain is often helpful to determine if there is peritonitis.

3. Missed appendicitis is one of the most common diagnoses resulting in malpractice claims.

4. Diarrhea is one of the most confusing symptom of appendicitis and patients often get misdiagnosed as gastroenteritis.

Clinical Summary

Perforation of appendicitis generally occurs after 48 to 72 hours of symptoms. Clinical symptoms differentiating perforated appendicitis or appendicitis with abscess from simple acute appendicitis include higher fever, systemic toxicity, diffuse abdominal tenderness and guarding (potentially a rigid abdomen), tender right lower quadrant mass and elevated markers of inflammation, including white blood cell count, absolute neutrophil count, and C-reactive protein.

Patients with perforated appendicitis do not like to move and feel most comfortable lying on their sides with the hips and knees flexed. They walk very slowly in a bent-over position with a shuffling gait while holding the right side of the abdomen and will refuse to hop or jump because of extreme pain. When initial perforation occurs, there may be some initial relief of pain, but until abscess is fully walled off, generalized peritoneal irritation is typically present.

Emergency Department Treatment and Disposition

Place all patients with suspected perforation on NPO status. Obtain CBC with differential, serum electrolytes including glucose, urinalysis, pregnancy test (as appropriate), and a C-reactive protein. Provide IV fluid resuscitation with crystalloids as clinically indicated. Provide adequate analgesia with morphine or other opiates. Consult surgery emergently and order CT, which may be foregone if the patient is taken to surgery before CT is obtained. CT gives detailed information about abscess formation and location, and may be used to plan drainage by interventional radiology (various protocols using rectal, oral, and IV contrast are used based on consultation with the radiologist). Once the diagnosis is confirmed, start broad-spectrum antibiotics with gram-negative and anaerobic coverage (eg, ampicillin, gentamicin, metronidazole).

Definitive management of perforated appendicitis varies from emergent surgery for septic patients to antibiotics to “cool off” the abscess followed by “interval appendectomy” several weeks later. These decisions are made by surgery.

Pearls

1. Preschool-age children are often difficult to evaluate for appendicitis and often present with perforated appendicitis.

2. Adequate fluid resuscitation and stabilization prior to surgical intervention is imperative.

3. Patients with intestinal obstruction are restless, and move around the bed, while patients with peritonitis are quiet, without movement.

Clinical Summary

Incarceration is the inability to reduce hernia sac contents into the abdominal cavity. Hernias containing intestines generally occur in boys, especially with a history of prematurity, and are caused by failure of the process vaginalis to fuse after testicular descent. In girls, hernia most often includes the ovary. Patients most often present with a history of an inguinal or scrotal bulge that becomes more prominent with increased abdominal pressure (crying, straining, coughing, laughing). Other symptoms include inguinal swelling alone or in conjunction with pain and vomiting (may become bilious from intestinal obstruction or strangulation), irritability, poor feeding, lack of bowel movements, and abdominal distension. Incarceration is more common in patients <2 years old. Clinical characteristics include a firm, immobile, and often tender and erythematous swelling. When the hernia is in the scrotum, the bowel is palpable distinct of the testicle.

Emergency Department Treatment and Disposition

If diagnosis is unclear, order an ultrasound to differentiate hernia from hydrocele, testicular torsion or other inguinal or testicular pathology. Incarcerated hernias need to be reduced emergently. Provide analgesia and sedation as needed and apply gentle constant manual pressure to decompress the sac and push it in. If the hernia is not reducible or if there is any concern for intestinal perforation or gangrenous bowel, consult surgery emergently for operative management. If there is concern for perforation, order upright or cross-table lateral plain radiographs to assess for free air. Admit patient for observation and surgical repair (usually after 24 hours to allow for resolution of edema) or discharge for delayed repair (after surgical consultation) with very specific instructions to return for recurrence.

Pearls

1. Always consider incarcerated hernia in inconsolable infants.

2. Do not try to reduce the hernia if there is evidence of peritonitis or toxicity.

3. The hernia may cause pressure on the spermatic cord, causing venous congestion and infarction of the testicle.

4. Placing the child in Trendelenburg and maximizing relaxation will aid in reduction.

Clinical Summary

Testicular torsion is most common in the newborn and the early adolescent. In adolescents, it occurs when there is a “bell-clapper” deformity: testis is not fixed within the tunica vaginalis, allowing twisting of the testicle on the spermatic cord, which obstructs blood flow. Patients present with acute onset of severe pain in the groin (sometimes with radiation to the abdomen), vomiting and a swollen, tender testicle often in a transverse lie and higher than usual. There may also be absence of the cremasteric reflex, erythema of the overlying skin, and lack of relief with elevation of the testicle (a negative Prehn sign). There may be a history of similar episodes as the testes can twist and untwist spontaneously. With delayed diagnosis, the pain may subside and there is thickening of the scrotal skin. Torsion occurs more often on the left side, likely from the increased length of the spermatic cord.

Emergency Department Treatment and Disposition

Consult urology or surgery emergently. Testicular viability is dependent on duration of testicular ischemia. If the diagnosis is unclear, obtain color Doppler sonography or nuclear scan to check blood flow to the testicle. Depending on how far and how many times the testicle is twisted on its vascular pedicle, the flow may range from “diminished” to “absent.” Manual detorsion to improve blood flow to the testicle may be attempted in the emergency department (ED) pending surgery by “opening the book” (externally rotating affected testicle) in two-thirds of the cases (keep in mind, there may be more than 360 degrees of twist), which should improve the position of the testicle, pain, and blood flow. If unsuccessful, rotation in the opposite direction may be necessary. Whether torsion is resolved manually or spontaneously, surgical exploration and fixation within the scrotum is required to prevent further episodes.

Pearls

1. Presume testicular torsion until proven otherwise in any boy with acute scrotal pain.

2. Perform testicular exam to exclude torsion in all boys with abdominal pain.

3. Recent history of trauma may accompany torsion and is often misleading.

4. If there is very high suspicion for torsion, do not delay scrotal exploration while awaiting a diagnostic study.

5. Patients with symptoms <6 to 12 hours are more likely to have a salvageable testicle. Even if symptoms are present >12 hours, patients must be explored emergently.

6. Sedation analgesia should be provided to aid in manual detorsion.

Clinical Summary

Blunt scrotal trauma can result in testicular dislocation, fracture or rupture, hematoma and/or hematocele. Patients present with pain (often accompanied by nausea and vomiting), swelling, and ecchymosis. In testicular dislocation, the testicle is out of the scrotum and found in the inguinal, abdomen, penile, or perineal area. Testicular fracture or rupture involves a break in the tunica albuginea, which can be indirectly seen on ultrasound as an irregular contour. A testicular hematoma is blood within the testicle, whereas a hematocele is an extratesticular collection of blood.

Emergency Department Treatment and Disposition

Examine the testes in all boys with pelvic or perineal trauma. A thorough exam of the scrotum is also necessary. If there is an empty well-developed scrotum, search for a possible dislocated testis, which must be relocated via closed or open reduction. Order ultrasound and consult urology. Provide adequate analgesia. Testicular fracture or rupture is a surgical emergency, as salvage is more likely within 24 hours. Manage small hematomas and hematoceles conservatively with pain management. Consult urology for drainage of large hematomas as testicular pressure may cause ischemia and atrophy.

Pearls

1. Consult urology and surgery early as testicular injuries are time-sensitive.

2. Administer adequate pain medication to optimize the examination.

3. Testicular torsion may present with a history of trauma.

4. Traumatic epididymitis presents in a delayed manner as a recurrence of pain.

Clinical Summary

Epididymo-orchitis is inflammation of the epididymis and the testes, either of which may be found in isolation (either epididymitis or orchitis) or together (epididymo-orchitis). In sexually active patients, Chlamydia trachomatis, Neisseria gonorrhea, Mycoplasma, Ureaplasma, or Escherichia coli (more likely with anal sex) are the most common pathogens. In younger patients, common organisms include E coli or other gram-negative uropathogens (usually in conjunction with a urinary tract infection [UTI]) and viruses including adenovirus, enterovirus, and mumps. Patients present with a relatively gradual onset of pain, swelling, and redness (as compared to torsion). Prehn sign is positive (pain may be relieved with elevation of the testis as opposed to torsion in which there is no relief; however, this is not a 100% reliable sign to differentiate the two). The testis is in normal vertical position and the cremasteric reflex is present. Patients may also complain of penile discharge and/or dysuria or urgency and frequency. If the inflammation is limited to the epididymis, the pain will be limited to the upper posterior pole of the testis. Complications of epididymo-orchitis include abscess formation and infertility.

Emergency Department Treatment and Disposition

Obtain urinalysis and urine culture in all patients and test for N gonorrhea and C trachomatis in sexually active adolescents with suspected epididymitis or orchitis. Consult urology and obtain scrotal ultrasound when diagnosis is unclear. It will show increased flow and edema to the affected area, likely with a reactive hydrocele. Treat sexually active patients with ceftriaxone and doxycycline for Gonorrhea and Chlamydia. Treat younger patients and those with a suspected UTI for the usual urinary pathogens with either trimethoprim-sulfamethoxazole or cephalexin. Prescribe scrotal support and NSAIDs for pain and follow-up with the pediatrician.

Pearls

1. Refer patients with UTI as cause for epididymitis or orchitis for urologic evaluation.

2. Acute epididymitis is the most common entity confused with testicular torsion. If infection spreads to the testis (epididymo-orchitis), it is often indistinguishable from testicular torsion on examination. Exclude torsion in an expeditious manner, if diagnosis is unclear.

3. Counsel adolescents with epididymitis or orchitis on safe sex and referred for comprehensive STD testing.

Clinical Summary

The appendix testis is a vestigial appendage on the upper pole of the testicle that may twist on its stalk, becoming necrotic and painful. This occurs more often in prepuberty (may occur at any age) and more frequently than testicular torsion. Patients present with pain and swelling of more gradual onset and less severity than seen with testicular torsion. There is tenderness and swelling localized to the superior lateral aspect of the testis and firm swelling distinct from the epididymis. Testis is with a normal vertical lie and the cremasteric reflex is present.

Torsion of the appendix testis resolves without intervention in 2 to 10 days as the appendage is resorbed. Differential diagnosis includes testicular torsion, acute epididymo-orchitis and other causes of acute scrotum (see Table 10.1)

Emergency Department Treatment and Disposition

Torsion of the appendix testis is a clinical diagnosis. Order ultrasound or nuclear scan if the diagnosis is uncertain and consult urology. If testicular torsion cannot be excluded, surgical exploration is warranted. If the diagnosis is clear, rest and analgesia is the treatment with a follow-up with the pediatrician.

Pearl

1. The classic sign of torsion of the appendix testis is “blue dot” of the ischemic appendage; although this may not be seen because of surrounding edema and skin thickening of the scrotal wall.

Clinical Summary

Vaginal foreign bodies are a common cause for foul and/or bloody vaginal discharge in the prepubertal child as is vaginal irritation or dysuria. Symptoms may vary from days to years. Toilet tissue is the most common vaginal foreign body (FB), although any FB may be found since prepubertal children are notorious for placing objects in various orifices.

Emergency Department Treatment and Disposition

Examine patient in either the “frog-leg” (supine) or “knee-chest” (prone) position. Irrigate with lukewarm water through a small catheter or angiocatheter for small pieces of toilet paper. Provide analgesia and/or sedation prior to removal of any FB, as surrounding tissues are sensitive and friable. Consult surgery for removal of FB in the operating room if there is any concern for erosion into surrounding structures. After successful removal, provide topical estrogen cream to hasten healing of mucosal lesions.

Pearls

1. Although child abuse must be in the differential for foul vaginal discharge, careful history taking and a detailed physical exam is needed to exclude FB.

2. Vaginitis secondary to FB will not resolve until FB is removed.

3. If an FB is found in 1 orifice (eg, vagina), all other easily accessible orifices, that is, ears and nose, should be inspected for additional FBs.

Clinical Summary

An imperforate hymen is usually an isolated anomaly. Patients present with hematocolpos (vaginal distension with menstrual products) or hematometrocolpos (distention of the uterus and vagina with menstrual products), causing abdominal pain, and a mass in a pubertal adolescent with primary amenorrhea. There may be a history of cyclic abdominal pain or symptoms associated with an abdominal mass, including constipation, urinary retention, or back pain.

A bluish or purplish bulge in the vaginal vault is noted in the adolescent. In the neonate or infant, it appears as a mucocele (vaginal distention with mucus secretions due to excessive intrauterine stimulation of an infant’s cervical mucus glands by maternal estrogens). Mucocele may resolve spontaneously. Differential diagnosis includes labial agglutination, congenital absence of the vagina, and “acquired imperforate hymen” from genital trauma of sexual abuse (scarring leading to imperforate hymen).

Emergency Department Treatment and Disposition

Obtain pelvic ultrasound to delineate anatomy for patients with unclear diagnosis or concern for other genitourinary abnormalities. Consult gynecology or surgery for urgent resection of the hymen in the adolescent and drainage of menstrual blood and debris. Reassure patients about the normality of their genitalia. In many cultures, integrity of the hymen is symbolic of virginity, and the patient and her family need to be reassured that surgical intervention does not alter this symbolic value.

Pearls

1. Do not puncture the membrane to relieve pressure as this may cause ascending infection.

2. Always perform a genitourinary exam in pubescent girls with abdominal pain.

Clinical Summary

Paraphimosis is a tourniquet effect on the distal foreskin and the glans that occurs when uncircumcised and phimotic foreskin is retracted behind the coronal sulcus. As edema of the distal structures increases, it becomes increasingly difficult to replace the foreskin to the normal position. Patients present with severe pain and swelling of the glans penis. They may have difficulty voiding and urinary retention (urethral obstruction due to edema).

Emergency Department Treatment and Disposition

Diagnosis is made visually; however, it is essential to take a careful history to verify that the patient is uncircumcised as severe balanoposthitis in the circumcised male or hair tourniquet may appear similar. Provide adequate analgesia with topical lidocaine jelly, oral or parenteral anesthesia, or dorsal penile nerve block. Promptly reduce the paraphimosis by first decreasing the edema with constant manual pressure and cold compresses for several minutes, then roll the foreskin back over the glans. If this is not successful, puncture the foreskin with either a 23- or 25-gauge needle (multiple punctures may be required) and manually express the fluid before rolling the foreskin back into place. Further measures include dorsal slit of the foreskin or emergency circumcision, which should be performed by urology or surgery. After reduction, instruct caregiver and patient not to retract the foreskin for several days, and to follow up with urology or surgery for consideration of circumcision.

Pearls

1. Infants with paraphimosis may present with inconsolable crying (because of pain).

2. Take care not to worsen the ischemia during reduction attempts.

3. Paraphimosis may be iatrogenic because of retraction of the foreskin for catheterization or medical exam. Always remember to return the foreskin to the proper position postmanipulation.

4. Instruct patients to return immediately for recurrence and be sensitive that adolescents are often shy about reporting problems with their genitalia.

Clinical Summary

Ovarian torsion occurs most often in the adolescent. Patients present with acute-onset pelvic pain, generally one sided, which may be accompanied with nausea and vomiting. A large cyst or neoplasm of at least 4 cm diameter is most often the precipitating factor; however, torsion does occur in normal ovaries, especially in preadolescence. A tender mass may be palpable. Patients may have a prior history of intermittent pain, when the ovary was torsing and detorsing. Similar to the testes, the viability of the ovary is dependent on the duration of compromised blood supply. Better outcomes are for those with clinical symptoms of less than 12 hours’ duration.

Emergency Department Treatment and Disposition

Consult gynecology and/or pediatric surgery. Provide adequate pain management and fluid resuscitation. Order ultrasound with Doppler flow for the evaluation of blood in the ovary, noting that this is not 100% sensitive or specific, especially if there is intermittent torsion. If there is a high clinical suspicion, consult surgery for exploratory laparotomy.

Pearls

1. Ovarian torsion must be treated as an emergent manner equal to testicular torsion.

2. The difficulty of diagnosis often delays surgical intervention. A high degree of suspicion is imperative.

Clinical Summary

Intestinal malrotation occurs during fetal development when the intestine does not fully rotate and thus does not allow attachment of the cecum in the right lower quadrant. This produces a mesentery that can twist on itself as well as “Ladd bands” that may produce intestinal obstruction. Patients present with bilious emesis and signs of intestinal obstruction; stools may demonstrate occult or frank blood. The younger the infant, the more likely obstruction will be severe with necrosis. The majority of cases present in the first year of life, but may present at any age.

Emergency Department Treatment and Disposition

Stabilize the patient as needed including resuscitation of shock. Place a nasogastric tube for decompression. Obtain CBC, electrolytes and glucose, lactate, and type and cross for evaluation and management of shock and preparation for surgery. Give broad-spectrum antibiotics (eg, ampicillin, gentamicin, metronidazole) for possible bowel necrosis and perforation. Consult surgery and order ultrasound or upper GI series (depending on radiology’s preference given the clinical scenario). With malrotation, US will show transposition of the usual alignment of the superior mesenteric artery and vein and upper GI will show abnormal position of the duodenojejunal flexure (ligament of Treitz). With volvulus, US will show a “whirlpool sign” (twisting of mesenteric vessels), and upper GI will show a “corkscrew sign” (spiraled appearance of duodenum and jejunum).

Pearls

1. Infants with bilious vomiting must be suspected to have malrotation with volvulus.

2. Infants may present with septic shock.

3. Patients found to have a malrotation of any type, even without current signs of obstruction must be evaluated by surgery to prevent an abdominal catastrophe.

Clinical Summary

Umbilical granulomas are granulation tissue persisting at the base of the umbilicus after cord separation. The mass is 3 to 10 mm, pedunculated, moist, and mucosal in appearance, and may be friable. No purulent discharge or redness of the skin is seen around the umbilicus. Differential diagnosis includes umbilical polyps and other remnants of the urachus or omphalomesenteric duct. Umbilical polyps are firm masses of intestinal or uroepithelium, generally larger than an umbilical granuloma, but otherwise similar in appearance. Polyps are distinguished from granulomas in that they do not respond to silver nitrate cauterization, and require surgical excision. Rarely, a complete connection remains between the umbilicus and bladder or intestine, because of failure of the urachus of omphalomesenteric duct to close. This is identified clinically by a patent fistula in the umbilical mass, draining urine or stool. Diagnosis is confirmed by sinogram. With any of these anomalies, further evaluation for associated GI or genitourinary anomalies is recommended.

Emergency Department Treatment and Disposition

Treat umbilical granulomas with application of topical silver nitrate. Blot the area dry, then roll the silver nitrate stick over the moist, pink tissue, leaving a grayish residue. Repeat treatments may be needed 1 to 2 times per week for several weeks, until the granuloma epithelializes.

Pearls

1. Moist, pedunculated umbilical masses can be safely cauterized using silver nitrate in the ED.

2. An umbilical mass with a draining fistula requires further evaluation with a sinogram and referral to a pediatric surgeon.

Clinical Summary

Umbilical hernias are caused by intestinal herniation through a persistent fascial opening called umbilical ring (normally allows passage of umbilical vessels from mother to fetus) that functionally closes spontaneously after birth, but complete closure of the fascial layers is not complete until about 5 years of age. An umbilical hernia presents at birth or shortly after as a protruding umbilicus. The mass is typically noted by parents to appear or enlarge when the infant is crying or straining, and may be firm during these activities, but should be soft and reducible when the infant is calm. Air content in the bowel can be felt in the mass, and the borders of the fascial opening can often be palpated. The vast majorities of umbilical hernias decrease in size and eventually close. The best predictor of failure to close is the size of the fascial opening (>1.5 cm).

Emergency Department Management and Disposition

An umbilical hernia that is reducible (when the infant is calm) is a benign condition, and only reassurance is recommended. Consult surgery urgently if signs of incarceration are present to prevent progression to strangulation. Otherwise, consider surgical referral for hernias that are increasing in size, symptomatic, or large and failing to decrease after 2 years of age.

Pearls

1. Umbilical hernias are very common usually self-resolving condition and surgical intervention is rarely needed.

2. Signs of incarceration include a hard, non-reducible mass, with or without persistent vomiting or signs of intestinal obstruction.