Patient Presentation
A 3-month-old female came to clinic with 2-3 days of diarrhea described as watery, yellow, without blood or mucous. She had emesis of formula only with at least 1/2 the feeding that is non-projectile. Her mother also noted that her umbilical hernia seems to be “turning blue” once in a while. She has been fussy the past 2-3 days but has been eagerly eating and is urinating well. Children at daycare have had diarrhea recently also. The past medical history is non-contributory. The review of systems shows no fever or upper respiratory tract infection symptoms, and she has a gluteal rash. The pertinent physical exam shows a slightly fussy female with normal vital signs and growth parameters in the 25-90%. She has gained weight from her 2 month appointment. Her abdominal examination shows an umbilical hernia of approximately 0.75 cm internal diameter ring with mild bluish coloring mainly at the ring. It was unable to be reduced. She had increased bowel sounds, but no organomegaly. Her diaper area showed a contact dermatitis rash.
The diagnosis of probably gastroenteritis with a possible incarcerated umbilical hernia was made. A laboratory evaluation of a basic metabolic profile was normal. The radiologic evaluation of an abdominal radiograph showed small bowel with distension, but no obvious obstructive pattern. A surgeon was consulted who, with great pressure, reduced the umbilical hernia. The patient was discharged home with instructions for treatment of gastroenteritis, but to return if the umbilical hernia reappeared, emesis or diarrhea increased or if the patient seemed to be overall worse. At her 4 month appointment, the patient was doing well.
Figure 93 – Lateral radiograph of the abdomen shows an umbilical hernia with a loop of bowel trapped within it.
Discussion
Umbilical hernias are commonly seen in pediatric patients. They usually are markedly improved by 1 year of age, and should be gone by 4-5 years of age. Hernias at this time are often repaired for cosmesis and to decrease the risk of incarceration often in adulthood. Usually abdominal contents or fluid that lie within the hernia’s pouch are easily reduced with very minimal pressure. A review of umbilical masses can be found here.
Incarcerated umbilical hernias are much more common in adults who have underlying reasons for increased abdominal presure including pregnancy, cirrhosis, abdominal transplantations, paracentesis, obesity and a variety of benign and malignant tumors.
Learning Point
Incarceration of umbilical hernias in children is uncommon to rare in the literature. In 1997, Vransky reviewed the literature and found 45 cases, and another paper reported 1 case. In 1998 one paper reported an additional 4 cases and in 1999 a fourth paper described 1 more. In 2006, Chirdan described 23 additional cases. While this is not a full systemic review of the literature, it appears that for the past ~ 80 years, less than 100 cases have been reported in the literature of incarcerated umbilical hernias.
It is important to note, that just because the literature does not report cases, does not mean that the incidence is necessarily low because the literature depends on individuals to report the cases and editors to publish the manuscripts. In both of his reports Vransky notes “… we believe that [umbilical hernia] incarceration is much more frequent than is generally supposed, and we report our plea for a more active therapeutic approach… especially in smaller [umbilical hernias] where incarceration is more probable.”
Questions for Further Discussion
1. How common are incarcerated inguinal hernias?
2. How are umbilical hernias formed?
3. What are the potential complications of laproscopic surgery involving the umbilicus?
Related Cases
- Disease: Hernia
- Age: Infant
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Hernias
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Vrsansky P, Bourdelat D. Incarcerated umbilical hernia in children. Pediatr Surg Int. 1997;12(1):61-2.
Simon HK. Radiological case of the month. Incarcerated umbilical hernia. Arch Pediatr Adolesc Med. 1997 May;151(5):519-20.
Papagrigoriadis S, Browse DJ, Howard ER. Incarceration of umbilical hernias in children: a rare but important complication. Pediatr Surg Int. 1998 Dec;14(3):231-2.
Vrsansky P. Incarcerated umbilical hernia in children: Comment. Pediatr Surg Int. 1999;15(7):527.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 