|Year : 2015 | Volume
| Issue : 2 | Page : 179-181
Clinical and histopathological profile of lesions of umbilicus
Vandana Laxmidhar Gaopande, Sanjay D Deshmukh, Siddhi Gaurish S Khandeparkar, Monica Anil Suryavanshi, Vinod R Patil
Department of Pathology, Smt Kashibai Navale Medical College and General Hospital, Narhe, Ambegaon, Pune, Maharashtra, India
|Date of Web Publication||13-Mar-2015|
Vandana Laxmidhar Gaopande
Department of Pathology, Smt Kashibai Navale Medical College and General Hospital, Off Katraj Bypass Highway Flyover, Narhe, Ambegaon, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Although lesions of umbilicus are encountered in clinical practice on a regular basis, surgical intervention is rarely required for them. Umbilical tissues are uncommonly received for histopathology. They formed 0.18% of the total specimens received. Aims: To study the clinical and histopathological characteristics of umbilical lesions received in the Surgical Pathology Department of a tertiary care hospital. Materials and Methods: This is a 2-year retrospective study. Records of the cases were reviewed and the histopathology slides were reassessed. Results: A total of 15 cases were found between the age range of 9 months and 45 years, with a male preponderance. Complaints of umbilical discharge/wet umbilicus and umbilical mass were the most common. In four cases, the umbilical lesion was associated with underlying congenital anomaly. Umbilical sinus (four cases) and umbilical granuloma (three cases) were the most common histopathological diagnosis. Two of the sinuses were pilonidal sinuses, which are rare lesions in this location. Conclusion: Umbilical mass or discharge associated with abdominal symptoms requires careful evaluation for congenital anomalies. Pilonidal sinus should be considered in a young hirsute patient with wet umbilicus.
Keywords: Persistent vitelline duct, pilonidal sinus, umbilical granuloma, umbilical lesions, umbilical sinus, urachal anomalies
|How to cite this article:|
Gaopande VL, Deshmukh SD, Khandeparkar SS, Suryavanshi MA, Patil VR. Clinical and histopathological profile of lesions of umbilicus. Med J DY Patil Univ 2015;8:179-81
| Introduction|| |
Surgical specimens consisting of tissues of the umbilicus are uncommon in histopathology practice. A total of 8246 surgical specimens were received in our Surgical Pathology Department of a tertiary health care center, of which 15 (0.18%) were of umbilical tissues in a 24-month duration. In this study, we present the common and uncommon lesions of this particular location.
| Materials and Methods|| |
A retrospective study of cases where the umbilical tissues were sent for histopathology was performed. The case papers of each case were reviewed. The histopathological slides were reassessed. Information was tabulated [Table 1].
| Results|| |
The youngest patient in this group was 9 months old and the oldest patient was 45 years. Five of the patients were in the pediatric age group. Eleven of the 15 patients were male. Umbilical discharge/wet umbilicus was the most common symptom, seen in 10 cases. In nine cases, the patients had an umbilical mass. In one case, the mass was clinically diagnosed as an omphalocele, and was accompanied by recurrent subacute intestinal obstruction. In five cases, both mass and discharge were seen together. In three cases, abdominal pain was a prominent symptom. Abdominal ultrasonography was performed in four cases and detected collection of fluid under the umbilicus in one case, and urachal fistula in one case, urachal cyst in one case and Meckel's diverticulum in one case.
The most common histopathological diagnosis was umbilical sinus (four cases), of which two were of pilonidal sinus. Umbilical granuloma (three cases) was the next common diagnosis. In one of the cases of umbilical granuloma, a Meckel's diverticulum was also present. There were two cases of chronic nonspecific omphalitis. Urachal abnormality with abscess formation was found in two cases. There was one case of umbilical adenoma. In three cases, the histopathology was inconclusive and was reported as cicatricial tissue.
| Discussion|| |
During intrauterine life, the umbilical cord contains paired umbilical arteries, umbilical vein, omphalomestenteric or vitelline duct (VD) (which connects the yolk sac to the midgut) and the allantois (urachus). The VD obliterates by the 9 th week of gestation and the urachus obliterates by the 4 th to 5 th months of gestation. In the newborn, the umbilical cord typically separates within 3 weeks, leaving a dry, star-like central abdominal scar that forms the umbilicus.
Delayed umbilical separation and omphalitis are the problems found in newborns and do not usually require surgery. In later childhood and in adults, umbilical mass and umbilical discharge or wet umbilicus are the most common presentation of disorders of the umbilicus. In our study, 10 of 15 patients complained of wet umbilicus/umbilical discharge. Nine of the 15 patients had an umbilical mass. Pain in abdomen was found in three of our cases. Yadav studied 29 cases of umbilical discharge in adults. He found that the discharge may be serous, sero-purulent, purulent, serosanguinous or urine. The most common cause (51%) was urachal anomalies. Umbilical infection postlaparoscopic surgery was the second most common cause. The other causes included umbilical hernia with ulceration, abscess, sinus, folliculitis, metastasis and pilonidal sinus.  In the present study, the causes of umbilical discharge were umbilical sinus including pilonidal sinus, umbilical granuloma, urachal anomalies, chronic nonspecific omphalitis and umbilical adenoma.
Umbilical lesions may be congenital or acquired. Congenital lesions include abnormal position or absence of umbilicus, patent urachus, patent VD, umbilical polyp and hernia. Acquired lesions include infections like omphalitis, umbilical vein phlebitis and umbilical granuloma. Neoplasms of the umbilicus are rare. They include the very rare primary adenocarcinoma  and metastasis (Sister Mary Joseph's Nodule). Umbilical nodules have been reported in primary tumors of the pancreas, colon, ovary, genitourinary tract tumors and lymphomas.  Umbilical endometriosis is an important differential diagnosis in females and may present as a mass or with discharge.  Recently, a primary umbilical melanoma was reported by Song et al.  Umbilical epidermoid cysts were reported by Mcclenathan. 
Of the five pediatric cases in our study, two were acquired conditions (umbilical granuloma and umbilical sinus) while three cases had a congenital problem (patent VD, patent urachus, umbilical polyp). Of the 10 adult cases in our study, two were due to congenital problem (urachal cyst and patent urachus), four were due to infections (with sinus formation in one case), two were pilonidal sinuses, while in three cases only cicatricial tissue was found (result of antibiotic treatment).
Remnants of the vitellointestinal duct (VD) may present as one of the following: Umbilical polyp, Meckel's diverticulum, patent vitellointestinal duct, vitellointestinal duct cyst and fibrous band extending from the umbilicus to the intestine.  MD [Figure 1]a is the most common pathology among symptomatic children with VD anomalies.  Complications of MD include intestinal obstruction due to intussusceptions or volvulus, bleeding, inflammation and trapping of foreign bodies and parasites within the diverticulum.  Urachal anomalies include patent urachus [Figure 1]b, urachal cyst, umbilical sinus and bladder diverticulum.  These urachal remnants are often subject to infection, and the route of infection may be lymphatic, hematogenous or vesical.  Congenital urachal abnormalities are twice as common in men as in women. A patent urachus accounts for 50% of the anomalies, urachal cyst for 30%, umbilical sinus for 15% and bladder diverticulum for 3-5%. 
|Figure 1: (a) Gross picture of Meckel's diverticulum (arrow) and (b) the transitional lining of the urachal tract|
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Umbilical polyp is a mass lesion that is often dark red in color, which does not respond to conservative treatments. On histopathology, it shows remnants of intestinal or urachal epithelium [Figure 2]a. It needs excision. It is often associated with an underlying VD anomaly. 
|Figure 2: (a) An umbilical polyp showing colonic mucosal lining and (b) granulomatous infl ammatory reaction around the hair shafts in pilonidal sinus|
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An umbilical granuloma presents as a moist, red, granular, mass lesion up to 1cm in size and shows inflammatory granulation tissue on histopathology. Umbilical sinus may develop as a result of persistent VD, persistent urachus and chronic inflammation. Pilonidal sinus [Figure 2]b is one of the rare causes of umbilical sinus. ,,, Pilonidal means nest of hair, and is derived from the latin words for hair (pilus) and nest (nidus). The condition was first described by Herbert Mayo in 1833. It is most commonly a painful nodule found near the coccyx presenting between the ages of 15 and 35 years. The condition can affect the umbilicus, axillary region or perineum rarely. In our study, two cases of pilonidal sinus were found. Ingrown hair is thought to be the cause of pilonidal sinus.  Coskun studied the etiological factors of umbilical pilonidal sinus and found that excessive body hair (hirsute) was the most important predisposing factor. Other significant factors were age, family history of pilonidal sinus, wearing tight clothes and obesity. 
| Conclusions|| |
Umbilicus being the site of entry of a variety of different structures into the body shows a variety of lesions. A lesion of umbilicus not responding to conservative treatment or associated with abdominal pain, rigidity/guarding should arouse the suspicion of a congenital underlying lesion and the patient should be accordingly investigated. In most cases, ultrasonography is sufficient to arrive at a diagnosis. Pilonidal sinus of the umbilicus is a rare lesion, but should be kept in mind when the patient is a young hirsute male.
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[Figure 1], [Figure 2]