Strangulated umbilical hernias in children

Case Report: The acute appendicitis and incarcerated umbilical hernia: a rare association

Introduction

One of the most prevalent congenital wall abnormalities in children, umbilical hernias are often linked to premature or small-for-gestational-age babies. In cases of intestinal malrotation or if the cecum is very movable, generalized peritonitis may facilitate the imprisonment of these hernias.

Case report

We described a case of a 4-month-old baby who had a prior reducible umbilical hernia with a history of fever, vomiting, poor appetite, and constipation for around 48 h. The patient experienced significant intestinal bloating, vomiting, irreducibility of the umbilical hernia, skin pigmentation, and erythema at the umbilical site within 2 days after hospitalization. When there was no free abdominal air, a direct abdominal x-ray revealed evidence of hydro-gas stasis and various hydro-aerial levels that were pertinent to the ileum. In order to reduce the hernia, the patient had an emergency surgical treatment where the hernia sac was isolated and released from the ileal loop, which was securely attached to a fibrin plate. When the herniary sac was opened, a gangrenous and perforated appendix was found inside. On the seventh postoperative day, the patient was released from the hospital after an uncomplicated postoperative stay.

Conclusion

Our patient's clinical presentation is similar to that of only one other case report involving a 25-day-old male patient. Our case presented with a variant of the clinical symptoms of the previously described umbilical hernia, which became unfixable and strangulated as a result of appendix inflammation. The appendix was discovered inside the hernia sac during surgery.

Routine Pediatric Surgical Emergencies: Incidence, Morbidity, and Mortality During the 1st 8000 Days of Life-A Narrative Review

BACKGROUND

Many potentially treatable non-congenital and non-traumatic surgical conditions can occur during the first 8000 days of life and an estimated 85% of children in low- and middle-income countries (LMICs) will develop one before 15 years old. This review summarizes the common routine surgical emergencies in children from LMICs and their effects on morbidity and mortality.

METHODS

A narrative review was undertaken to assess the epidemiology, treatment, and outcomes of common surgical emergencies that present within the first 8000 days (or 21.9 years) of life in LMICs. Available data on pediatric surgical emergency care in LMICs were aggregated.

RESULTS

Outside of trauma, acute appendicitis, ileal perforation secondary to typhoid fever, and intestinal obstruction from intussusception and hernias continue to be the most common abdominal emergencies among children in LMICs. Musculoskeletal infections also contribute significantly to the surgical burden in children. These "neglected" conditions disproportionally affect children in LMICs and are due to delays in seeking care leading to late presentation and preventable complications. Pediatric surgical emergencies also necessitate heavy resource utilization in LMICs, where healthcare systems are already under strain.

CONCLUSIONS

Delays in care and resource limitations in LMIC healthcare systems are key contributors to the complicated and emergent presentation of pediatric surgical disease. Timely access to surgery can not only prevent long-term impairments but also preserve the impact of public health interventions and decrease costs in the overall healthcare system.

OUP accepted manuscript

Incarceration of an umbilical hernia (UH) rarely occurs in the pediatric population. They usually resolve spontaneously or are treated after the child turns 4–5 years old [1, 2]. Risk factors for incarceration have been identified, but little is understood about how incarceration of an UH occurs.

A joint analysis using exome and transcriptome data identifiescandidate polymorphisms and genes involved with umbilical hernia in pigs

BACKGROUND

Umbilical Hernia (UH) is characterized by the passage of part of the intestine through the umbilical canal forming the herniary sac. There are several potential causes that can lead to the umbilical hernia such as bacterial infections, management conditions and genetic factors. Since the genetic components involved with UH are poorly understood, this study aimed to identify polymorphisms and genes associated with the manifestation of umbilical hernia in pigs using exome and transcriptome sequencing in a case and control design.

RESULTS

In the exome sequencing, 119 variants located in 58 genes were identified differing between normal and UH-affected pigs, and in the umbilical ring transcriptome, 46 variants were identified, located in 27 genes. Comparing the two methodologies, we obtained 34 concordant variants between the exome and transcriptome analyses, which were located in 17 genes, distributed in 64 biological processes (BP). Among the BP involved with UH it is possible to highlight cell adhesion, cell junction regulation, embryonic morphogenesis, ion transport, muscle contraction, within others.

CONCLUSIONS

We have generated the first exome sequencing related to normal and umbilical hernia-affected pigs, which allowed us to identify several variants possibly involved with this disorder. Many of those variants present in the DNA were confirmed with the RNA-Seq results. The combination of both exome and transcriptome sequencing approaches allowed us to better understand the complex molecular mechanisms underlying UH in pigs and possibly in other mammals, including humans. Some variants found in genes and other regulatory regions are highlighted as strong candidates to the development of UH in pigs and should be further investigated.

Umbilical shapes predict future protrusion in pediatric umbilical hernias

BACKGROUND

This study was conducted to evaluate the incidence and early predictive factors of the development of protuberant umbilicus in pediatric umbilical hernia patients.

METHODS

In this retrospective visual and chart review, patients younger than 3 months with umbilical hernias who initially visited Ina Central Hospital from April 2011 to March 2017 and were followed until they started to walk (at the age of 1 year) were evaluated. The umbilici of the patients at the age of 1 year were classified into two types based on their appearance: concave and protuberant umbilici. Single-factor and logistic regression analyses of the association between the appearance of the umbilicus at the age of 1 year and various clinical data were performed.

RESULTS

Of the 103 patients, 72% had concave umbilici, and 28% had protuberant umbilici. Single-factor analysis showed significant differences in the umbilical shapes at the initial visit (P < 0.001) and straining habit (P < 0.001). The most ideal logistic regression model demonstrated that umbilici of the highly inflated balloon type (odds ratio, 27.00; 95% confidence interval odds ratio, 5.60-130.08) and crescent type (odds ratio, 14.34; 95% confidence interval odds ratio, 4.22-48.77) were more likely to develop into protuberant umbilici.

CONCLUSIONS

Umbilical shapes at the initial visit can be used to predict the future development of protuberant umbilici in pediatric patients with umbilical hernias.

Association between Age and Umbilical Hernia Repair Outcomes in Children: A Multistate Population-Based Cohort Study

OBJECTIVE

To evaluate whether patient age or other sociodemographic and clinical characteristics are associated with recurrence or unplanned related hospital revisits after pediatric umbilical hernia repair.

STUDY DESIGN

We performed a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases of 7 states. Pediatric umbilical hernia repairs performed at any hospital or surgery center in 2010-2014 were included. Hernia recurrences and occurrences of unplanned and related hospital revisits within 30 days were evaluated.

RESULTS

Of 9809 included patients, 52.0% were female and 50.5% were black. The 3-year hernia recurrence rate was 0.57% (95% CI 0.42, 0.73). In multivariable analysis, the recurrence rate was higher in children <4 years of age than in children 4-10 years of age (hazard ratio [HR] 1.93, 95% CI 1.09, 3.44). Unplanned related hospital revisits within 30 days occurred in 2.5% of patients. Patient characteristics associated with the risk of an unplanned related hospital revisit included age <4 years (HR 2.17, 95% CI 1.70, 2.77) or >10 years (HR 2.11, 95% CI 1.46, 3.05), public insurance (HR 2.10, 95% CI 1.58, 2.79), asthma (HR 1.74, 95% CI 1.32, 2.29), and initial presentation to the emergency department (HR 2.46, 95% CI 1.08, 5.61).

CONCLUSIONS

Rates of recurrence and unplanned related hospital revisits following pediatric umbilical hernia repair are higher in children younger than 4 years of age. These findings support delaying the repair of asymptomatic umbilical hernia in children until 4 years of age.

Management of asymptomatic pediatric umbilical hernias: a systematic review

INTRODUCTION

Uncomplicated pediatric umbilical hernias are common and most close spontaneously. No formal practice guidelines exist regarding the optimal timing and indications for repair. The objective of this review is to examine the existing literature on the natural history of pediatric umbilical hernias, known complications of repair and non-operative approaches, and management recommendations.

STUDY DESIGN

A systematic literature search was performed to identify publications relating to pediatric umbilical hernias. Inclusion criteria comprised studies addressing recommendations for optimal timing of repair, evidence examining complications from hernias not operatively repaired, and research exploring the likelihood of pediatric umbilical hernias to close spontaneously. In addition, the websites of all pediatric hospitals in the United States were examined for recommendations on operative timing.

RESULTS

A total of 787 manuscripts were reviewed, and 28 met criteria for inclusion in the analysis. Studies examined the likelihood of spontaneous closure based on child's age and size of hernia defect, complications of unrepaired umbilical hernias including incarceration, strangulation and evisceration based on child's age and size of defect, incidence of postoperative complications and current recommendations for timing of repair. In addition, 63 (27.5%) of the United States pediatric hospital websites published a wide range of management recommendations.

CONCLUSION

Despite the high prevalence of pediatric umbilical hernias, there is a paucity of high quality data to guide management. The literature does suggest that expectant management of asymptomatic hernias until age 4-5years, regardless of size of hernia defect, is both safe and the standard practice of many pediatric hospitals.

TYPE OF STUDY

Review Article.

LEVEL OF EVIDENCE

Level IV.

Congenital genitourinary abnormalities in children with Williams-Beuren syndrome

OBJECTIVE

Williams-Beuren syndrome (WBS) is an autosomal dominant disorder caused by a gene deletion on chromosome 7q11.23. Patients with WBS usually show a group of features such as developmental delay, cardiovascular anomalies, mental retardation, and characteristic facial appearance. Abdominal wall defects, external genitalia anomalies, and structural abnormalities of the urinary tract have been scarcely evaluated and were the focus of our study.

MATERIALS AND METHODS

We prospectively evaluated 41 boys and 38 girls with WBS, with a mean age of 8.8 ± 4.1 (range 3-19 years). All patients were examined for the evaluation of inguinal and umbilical hernias and genital anomalies. All patients were offered a radiological evaluation, including urinary tract ultrasound, voiding cystourethrogram, and dimercaptosuccinic acid renal scintigraphy (DMSA scan).

RESULTS

Of the 41 boys, 30 (73.1%) had abnormalities on physical examination, including bilateral undescended testis in 13 (31.7%), retractile testis in four (9.7%), hypospadias in four (9.7%), and unilateral cryptorchidism in three (7.3%) patients. Of the 38 female subjects, 17 (44.7%) had at least one abnormality, including umbilical hernia in 11 (28.9%), unilateral inguinal hernia in four (10.5%), and bilateral inguinal hernia in three (7.8%) patients. Uroradiological abnormalities were found in 41 patients (51.9%). On sonography, six (7.6%) patients had unilateral hydronephrosis, three (3.8%) had a duplicated collecting system, and two (2.5%) had kidney stones. On DMSA, performed in 36 patients, four (11.1%) had unilateral renal scarring and two (5.5%) had bilateral renal scarring. Cystourethrography was obtained from 56 patients, of whom 27 (48.2%) had bladder diverticulum, 18 (32.1%) had bladder wall trabeculation, and three (5.3%) had vesicoureteral reflux. We found no association of urological abnormalities with cardiovascular defects.

CONCLUSIONS

Patients with WBS have a high prevalence of abdominal wall, external genitalia, and urological abnormalities, emphasizing the importance of proper physical examination and radiological investigation in this population.

Low risk, but not no risk, of umbilical hernia complications requiring acute surgery in childhood

AIMS

Umbilical hernias are a common finding in the paediatric community, with a preponderance to affect Afro-Caribbean and premature children. The rate of incarceration varies greatly between populations. Therefore, it is valuable to obtain some Australian data on this topic.

METHODS

We undertook a retrospective study of the records of all patients who underwent umbilical hernia repair over a 12-year period of between October 1999 and May 2012 at Princess Margaret Hospital. From this group, all patients that had an umbilical hernia repair for reason of acute complication were identified and analysed for age, ethnicity and co-morbidities.

RESULTS

Between October 1999 and May 2012, 433 umbilical hernias were repaired at Princess Margaret Hospital, five of which were as the direct result of an acutely complicated umbilical hernia. The mean age of hernia repair was 5 years old, and the mean age of acute complication was 5 years old. Out of the patients with acutely complicated umbilical hernia, there were no Afro-Caribbean patients, and one was premature complicated by hyaline membrane disease and broncho-pulmonary dysplasia.

CONCLUSIONS

Western Australia has an incidence of acutely complicated umbilical hernia requiring operative intervention of 1:3000 to 1:11,000. On an international scale, this is low, and studies with similar incidence do not advocate for immediate repair of all identified umbilical hernias. The authors believe repair should be guided by patient and guardian, but if there is an episode of incarceration, acute repair is advised.

An overview of the highly pathogenic H5N1 influenza virus

Since the first human case of H5N1 avian influenza virus infection was reported in 1997, this highly pathogenic virus has infected hundreds of people around the world and resulted in many deaths. The ability of H5N1 to cross species boundaries, and the presence of polymorphisms that enhance virulence, present challenges to developing clear strategies to prevent the pandemic spread of this highly pathogenic avian influenza (HPAI) virus. This review summarizes the current understanding of, and recent research on, the avian influenza H5N1 virus, including transmission, virulence, pathogenesis, clinical characteristics, treatment and prevention.

Omentum in the pediatric umbilical hernia: is it a potential alarm for the appearance of complications?

Umbilical hernia is a common benign condition which resolves spontaneously during the first five years of life. However, in certain cases there are some characteristics which may be indicative of a different prognostic approach, as they increase the possibility of complications. The two cases of umbilical hernia that we describe here were treated operatively and revealed the presence of strangulated and adhered omentum, respectively. Reflecting on the adhesive properties of the omentum, we hypothesized that this may occur more often than it is believed, especially in those cases that are described as recurrent symptomatic herniations. In such cases, there should be increased alert for the possibility of complications during the period of the conservative expectance for resolution.

Incarcerated umbilical hernia leading to small bowel ischemia

A 59-year-old male with history of hepatitis C, refractory ascites requiring multiple paracentesis and transjugular intrahepatic portosystemic shunt placement presented to the emergency department with 2 days of abdominal pain. Physical examination revealed blood pressure of 104/66 and pulse of 94. The abdomen was remarkable for distention and a tender incarcerated umbilical hernia. The skin overlying the hernia was pale with areas of necrosis. The patient immediately underwent laparotomy which was successful.

Current management of umbilical abnormalities and related anomalies

Prenatally, the umbilicus is of paramount importance, providing the gateway between the mother and the fetus. As the fetus becomes increasingly autonomous at the end of the second month of fetal life, the connections (vitelline, urachal) diminish in significance and involute. Disturbances in this process can result in a wide variety of abnormalities, ranging from relatively minor defects identified at birth (umbilical granulation tissue) to life-threatening complications quiescent until late adulthood (urachal carcinoma). This section will review the 'state of the art' in evaluation and management of these umbilical and related abnormalities.