EpistemisPainful and irreducible umbilical protrusion in the infant
Specialty: Pediatrics.
Why it occurs
- Incarcerated umbilical hernia (entrapment of an intestinal loop or omentum within the unclosed defective umbilical ring, a rare but serious complication in pediatrics)
- Strangulated umbilical hernia (ischemic vascular compromise of the incarcerated tissue due to constriction of the umbilical ring, which may progress to necrosis and perforation)
- Associated acute omphalitis (bacterial infection of the periumbilical subcutaneous tissue that inflames the hernial sac simulating an obstructive complication)
- Infected umbilical granuloma or persistence of the omphalomesenteric duct (malformation that can simulate a painful mass in the umbilical region)
Initial workup
The diagnosis of incarceration or strangulation of an umbilical hernia is clinical and constitutes a surgical emergency. In case of doubt or to evaluate the involvement of the intestinal loop prior to surgery: Ultrasound of the abdominal wall and umbilical region with color Doppler (to assess the presence of fluid in the hernial sac, the thickness of the wall of the herniated intestinal loop and the absence of blood flow in the trapped tissue). Simple abdominal x-ray (to rule out intestinal obstruction with air-fluid levels and pneumoperitoneum in case of perforation).
red flags
Umbilical protuberance that becomes extremely painful to the touch, hard, tense and that cannot be reduced (reintroduced into the abdomen) by gentle and sustained pressure; discoloration changes in the skin overlying the hernia, becoming erythematous, violaceous, purplish or blackish (unequivocal sign of ischemic compromise/strangulation); presence of recurrent vomiting, initially alimentary and later bilious; progressive and painful abdominal distension with absence of gas emission and bowel movements; fever, tachycardia or signs of septic shock.
Standard management
- The definitive treatment of strangulated or incarcerated umbilical hernia refractory to gentle manual reduction maneuvers is urgent surgical repair — umbilical hernioplasty). Preoperative pain management with Fentanyl (fast-acting opioid analgesic; dose of 1 to 2 mcg/kg intravenously or intranasally under close respiratory monitoring) or Metamizole sodium (dipyrone; dose of 20 mg/kg slow IV
- Prophylactic or therapeutic broad-spectrum intravenous antibiotics such as Cefotaxime (dose of 100-150 mg/kg/day IV divided every 6-8 hours) plus Metronidazole (dose of 30 mg/kg/day IV divided every 8 hours) if intestinal necrosis or perforation is suspected.
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Pediatrics
- Listed causes
- 4
- Treatment options
- 2