Acute Umbilical Complaints in the Pediatric ER
description
Transcript of Acute Umbilical Complaints in the Pediatric ER
Acute Umbilical Complaints in the Pediatric ER
Or“my babies navel looks/smells
funny”
2
Issues Umbilical - Case 1• 9 week girl infant. Presents to PLC-ER• Swelling of the umbilicus for ~5 hours• Erythema and a central Umbilical “lump”
noted• No fever• Some poor feeding with no vomiting for less
than a day• ~6 wet diapers past 24 hours
3
Issues Umbilical - Case 1• 5.11 kg, Cap refill <3 sec• T 36.4, R28, P 145, BP 78/49• Alert, no distress• N H&N• N chest and HS• Soft benign abdomen with no masses• Central, red umbilical bulge within skin cuff
(cushion)• Small volume thin purulent drainage?• Slight erythema 4-7o’clock? No induration or
demarcation
4
Issues Umbilical• Referred to ACH-ER with:
“? Umbilical hernia, R/O Omphalitis”
ACH ER exam similar overall• C&S of Umbilical “discharge”• CBC, Lytes• Felt likely to be Omphalitis• Referral to General Surgery• Ancef 25 mg/kg commenced
5
Issues Umbilical• CBC• WBC 9.7, Neuts 2.6• Hb 106, Platlets 522• Na 138, Cl 103, K 4.7, HCO3 23• Cr 17, Urea 2.2• U/A neg
6
Issues Umbilical• General Surgical Opinion (in the am!)• Likely omphalitis• Consider infected urachal remnant
• Admitted• Change to IV clindamycin• U/S booked
7
Issues umbilical• In Hospital course• Always remained afebrile• C&S umbilical discharge “scant skin flora
only”• U/S abdomen:• Swollen protruding umbilicus noted to be filled
with echogenic material. A sinus tract is identified which extends form the lower umbilicus and connects to the superior and anterior wall of the bladder in the midline. The appearance is consistent with a patent urachus.
8
Issues Umbilical• Day 4 • Discharged home for urgent elective repair
to be booked• Clindamycin oral course
9
Objectives of Naval Mission• Discuss omphalitis • Discuss common cord care• Understand the non-infectious
abnormalities that can occur in the umbilicus, notably in the infant
• Not to discuss • Umbilical hernia management• Case room cord examination and
implications
10
Normal Cord care• Policies vary greatly in developing vs
developed countries• Marked decrease in incidence of Omphalitis in
developed countries • ~0.7% vs up to 6 %
• In developed countries:• Cochrane review shows no form of cord
cleaning/antiseptic is better than dry cord care• In developing countries antiseptics in cord care
markedly decrease death and omphalitis (chlorhexidine, AgSulfadiazine, Triple dye…)
11
Cord Separation• Normal timing of ~1 week or less for
separation• Prolonged by certain agents• 70% alcohol: ~17 days• Triple dye: 3-8 weeks
• True “delayed” separation (without agent application) is in excess of 3 weeks
12
Umbilical infection• All cords are nearly immediately
colonized • Staph and other gm+ves within hours• Enteric organisms shortly thereafter
• Devitalized tissue is a good bacterial growth medium
• Mild discharge and absent inflammatory change, even with some odor is usually still a normal occurrence.• No proof for or against Rx with Alcohol, Bacitracin
or Mupirocin…but many choose this.• When does this constitute early Omphalitis?
13
Omphalitis• Predominately Neonatal• Mean age of onset in term infants is 3.5
days• Infection of umbilicus and/or surrounding
tissues• Purulent (+/-bloody) drainage from stump• Surrounding induration, erythema,
tenderness• BUT• Lethargy, fever, Irritability, poor feeding
suggest more severe infection/impending sepsis
14
Omphalitis
• Complications:• Sepsis / death• Septic umbilical arteritis/portal vein thrombosis• Peritonitis/liver abscess/intestinal gangrene• Small bowel evisceration• Necrotizing fasciitis
• Present-day Mortality: 7-15%
15
Case 2• 14 day infant girl transferred to ACH-ICU
for umbilical infection• 41 weeks GA• C/S for fetal distress• APGARs 81 & 95
• GBS+ve • Passed N mec. At 24 hours • No jaundice• Breast fed/BM 8x/day• Cord loss ~1 week of age
16
Case 2• Day 11• Some peri-umbilical redness, afebrile• Poor evening feeding
• Day 12• Worsening erythema, wider area• Abdomen appeared “puffy”• T = 38.50C• To local community hospital; blood-streaked stool in
ED, and with all serial later BMs• Much worse feeding and lethargy• Sepsis workup/LP/Ampicillin and Cefotaxime and
admitted
17
Case 2• Day 13• General progression of anorexia, and
increasing abdo wall abnormalities. • U/S abdomen, and transferred to ACH
overnight• Day 14 ACH - PICU• Change to Flagyl, Meropenum, Clindamycin.
And Gentamycin• Surgery/Plastics consult
18
Case 2• Physical• 88/60, 153,100%RA, 37.5, 40, 4.0Kg• AF flat, no jaundice• CVS N save CRT “2-5 seconds”• No increased WOB• Mottled extremities• Distended abdomen. Black umbilicus,
surrounded by an inner purple and outer white halo, both non-blanching. Rt > Lt, ~30% of abdo wall
• Whole remainder of abdomen wall is erythematous
19
Case 2• Lab • WBC of 33.7• CRP 72.8• Hb 148, Platlets 501
• To ACH-OR for debridement, and bowel inspection for R/O NEC• Abdo wall biopsy and C&S• Bowel observed to be vital without NEC• Umbilicus and surrounding tissues resected
including necrotic skin and abdo. wall to healthy fascia
• Frozen section biopsy consistent with Nec Faciitis
20
Case 2: Intra-operative, Post Umbilical Resection
21
Case 2: Intra-operative, Post Umbilical Resection
22
Case 2• OR visits on PICU-days 1,2,4,6 and 8 for
serial lesser debridements and bowel inspection
• Wound closure PICU day 8 but subsequent dehisence day 19
• Change to tazocin/vancomycin day 7• Wound grew • Enterococcus faecalis• Coag neg Staph• Actinomyces
23
Case 2
• Day 12 - extubated• Day 13 - to the ward• Day 19 - Wound dehisced• Day 30 - discharged home• All Abx discontinued • planned delayed closure abdo. wall ~2
weeks later
24
Omphalitis• Risk factors• LBW• Prolonged labor• PROM• Non-sterile delivery• Umb.A. cathetrization• Home birth• Improper cord care
• (cow dung, bentonite clay)
• Immune abnormalities
• Poorer Prognosis• Male• Premature• “Septic delivery”
• (including un-planned home delivery)
• Temperature instability• Necrotizing fasciitis
• (up to 85% mortality)
25
Omphalitis/Any Soft Tissue Infection
• There is a continuum of severity:Cellulitis
Infection of skin and S.C. fat
Necrotizing fasciitisInfection of skin, S.C. fat and superficial and deep fasciae
Myositis/myonecrosisDeep muscle infection with muscle death
26
Omphalitis/Any Aggressive Soft Tissue Infection
• Should be presumed to be poly-microbial at outset• “the usual suspects” in Omphalitis:• Staph Aureus• Gp A Strep• Coag Neg Staph• Enterococci• Gm Negs: E Coli, Klebsiella P., Proteus Mirabilis…• Anerobes: Bacteroides, Clostridium
perfingens/tetani
27
Omphalitis• Pathology of infection is presumed to be
polymicrobial from the outset• Abx must cover for this, and include:
• Anti-stahpylococcal penicilin or vancomycin• Aminoglycoside• Probable Clinamycin or Metronidazole
Esp. if maternal chorioamnionitis and/or foul discharge, for anaerobic coverage
28
Omphalitis
• Necrotizing Fasciitis• Rare complication of omphalitis• Polymicrobial• Involves skin, subcutis, superficial and deep
fasciae• Rapid spread is typical• Bacteremia, systemic toxicity, and shock in
high proportion. Death 60-85%• Early aggressive surgical intervention, broad
spectrum antibiotics, and supportive ICU care
29
Case 3• 38 2/7 week boy• 30 yr G1P1 mother, N Vtx Vag delivery• APGARs 81 and 85
• Short ACH transfer Day 1-3 for ?ileal atresia…final Dx Meconium plug
• Day 13• Peri-umbilical redness noted by family
30
Case 3• Day 14• Admitted to local hospital• Dx Omphalitis• Ampicillin and Gentamycin
• Day 15• Increasing redness in abrupt fashion: 5cm
above and 3cm below umbilicus• Transfer to ACH ICU• Dx Omphalitis, R/O Necrotizing Fasciitis
31
Case 3• ICU:• Not toxic• Abdo wall is only abnormality of serious note• WBC 16.5, N diff, INR N, Lytes N and Neg AG• Urgent tissue biopsy• No Nec Fasciitis; consistent with cellulitis• Neg gram stain
• Neg blood and urine C&S.• Surface Umb C&S from Primary hospital• Coag neg staph, and enterococcus faecalis
32
Case 3• I.D. Service: Antibiotics changed to • Meropenum, Clindamycin, and Gentamycin
• Day 16• Child improves sufficiently that ward transfer
is in process…..then oliguria unresponsive to fluids arises
• Scrotal swelling and severe progressive abdominal wall edema
• ICU stay maintained
33
Case 3• Day 17• 03:00 Resp failure/ETT• 05:00 dobutamine infusion• 05-10:00 progressive metabolic acidosis• 10:00 to OR• Abdominal exploration. Healthy bowel. • Abdo wall : Excision of navel and surrounding
tissue. Biopsy now positive for Necrotizing fasciitis• Deterioration: • with coagulopathy, WBC up to 49.5, INR elevated,
ARDS / pulmonary hemorrhage
34
Case 3• Day 17• Progressive deterioration and difficulty
ventilating. Rising Cr up to 180• 13:30 back to OR• Abdominal compartment syndrome• Bowel “eviscerates” under pressure and
ventilatability markedly improves…bowel seems healthy; Abdo Wall Margins still look healthy, and back to ICU with bowel encased in a “silo bag”
35
Case 3• Severe oliguria• Lines placed and dialysis commenced• Poor tolerance with repeated hypotension and need
for fluid bolusing
• Day 18• Several bradycardic arrests• Progressive instablilty and dialysis
discontinued• Family agree to discontinue all supportive Rx• 04:20 child pronounced
36
Case 3• C&S from initial umbilical ACH biopsy• Coag neg staph• Enterococcus faecalis• Clostridium sordellii
• Autopsy conclusion• Necrotizing faciitis of poly-microbial nature• Sepsis
37
Conclusion
Respect Omphalitis
38
Something is wrong with my babies Navel
• Umbilical Granuloma
• Omphalo-mesenteric duct remnants
• Urachal remnants
39
Case 4• 12 day infant girl
• 41 3/7 weeks, vacuum assisted SVD• GBS -ve• Thriving• Cord dehisced day 7• Umbilicus raw, oozing with sero-sanguinous
discharge since
40
Case 4• Looks well• P 165, R 26, T 37.1, BP 76/42• General Exam Normal• No peri-umbilical redness• Moist “nodule” of pinkish-red tissue over
stump site. Bleeds easily
• ?Umbilical Granuloma (vs some other developmental lesion)…Referred to Surgery Clinic DDR
41
Case 4• In clinic 1 month later• Major lump had “fallen off” and moist base
was cauterized with AgNO3
• Re seen 3 weeks later:• Area dry and fully healed
• Diagnosis:
Umbilical Granuloma
42
Umbilical Granuloma• Most common cause of umbilical mass
and umbilical drainage• Usually post cord separation• Persistent drainage of serous or sero-
sanguinous fluid around the umbilicus• A mass of pink granulation tissue at
umbilical base• Moist• Pink• Friable• Soft• Often pedunculated • Usually 3-10 mm
43
Umbilical Granuloma• Treatment:
• AgNO3 local Rx 1-2 x per week• If it persists post 3-4 Rx sessions • Can be ligated (be sure its not a polyp!) or
referred to general surgery for formal excision
44
Omphalo-mesenteric Duct Remnants
• Omphalo-mesenteric duct (Viteline duct):
• Connects the developing GI tract to yolk sack
• Regresses by ~9th week GA• Disruption of this regression causes the list
of abnormalities:
45
Vitelline, or Omphalomesenteric Duct Embryology
46
OMD Remnants• Umbilical fistula• Complete patency of OMD with stoma-like
connection to the terminal ileum• Partial persistence of OMD• Fibrous band umbilicus to ileum• “Distal” remnant - OMD-enteric cyst• “Proximal” remnant - Meckel’s diverticulum• Umbilical polyp - a mucosal remnant in the
umbilical stump
47
48
OMD remnants• Fibrous band • can cause volvulus; obstruction and/or volvulus
are most common infant presentation
• Umbilical Polyp• Usually enteric, but occasionally urachal origin.
Rarely pancreas, liver• Firm masses. No response to AgNO3,and must be
surgically excised
• OMD cyst • often asymptomatic, or may be an umbilical or
abdominal mass; occasionally infected
49
Urachal Remnants• Urachus is the embryologic descendant
of the allantois.
• Allantois is the most distal projection of the primitive gut, projecting into the extra-embryonic cord. Of it’s Intra-embryonic portions:• The bladder = proximal portion.• The urachus = more distal portion.
50
The Allantois
51
Urachal Remnants• Urachal fistula - complete patency of the
urachus• Urachal cyst - remnant along tract
(usually lower 1/3)
• Urachal sinus Blind umbilical tract, unconnected to the bladder
• Vesico-urachal diverticulumAntero-superior midline bladder dome
• Umbilical (urachal) polyp
52
53
Urachal Remnants• Ultrasound is the ideal investigation for
initial definition
• Sinogram for patent urachus (“fistula”) or urachal sinus are other options
• Renal U/S and VCUG have also been recommended
54
Urachal Remnants• Presentations:• May be subtle with erythema +/- drainage
• Umbilical discharge or Omphalitis spectrum
• Umbilical pain or retraction on micturition
• Umbilical mass or cyst
• Peri-umbilical pain
55
Urachal Remnants• All need to be excised
• In adults, 50% have malignant (adneocarcinoma) changes at the time of excision (nil in children)
• Cuff of normal bladder mucosa is excised during resection
56
Questions?
57
References1) Vane D.W. et al “Viteline Duct Abnormalities:
Experience with 217 Childhood Cases Arch surg122:542, 1987
2) Pomeranz A. “Anomalies, Abnormalities and Care of the Umbilicus” Pediatric Clinics of N.A. 51:819, 2004
3) Rescorla F. J. “Hernias and Umbilicus” in Principles and Practice of Pediatric Surgery, volume 2, 2005
4) Cilento B. G. et al “Urachal Anomalies: Defining the Best Diagnostic Modalitiy” Urology52:120, 1998.
5) Ashley R.A. et al “Urachal Anomalies: a Longitudinal Study of Urachal Remnants in Children and Adults” J Urol 178:1615, 2007
6) Cushing A.H. “Omphalitis: A Review”Pediatr Infect Dis 2:282, 1985
58
References7) Sawardekar K.P. “changing Spectrum of Neonatal
Omphalitis” Pediatr Infect Dis J 23:22, 20048) Mason W.H.et al “Omphalitis in the Newborn
Infant”Pediatr Inf Dis J 8:521, 19899) Kosloske A.M. “Cellulitis and Necrotizing Fasciitis of the
Abdominal Wall in Pediatric Patients”. J Pediatric Surg 16:246-251, 1981
10)Simon N.P. “Changes in Newborn Bathing Practices may Increase the Risk for Omphalitis” Clin Pediatr 43>763-767, 2004
11) Louie J.P. “Essential Diagnosis of Abdominal Emergencies in the First Year of Life”Emer Med. Clinics of N A 25:1009-1040
12) Zupan J. et al “Topical Umbilical Cord Care at Birth(Review)”Cochrane Library 2008, Issue 3
59
References13) Mullany L.C et al “Development of a Clinical Sign Based
Algorithm for Community Based Assessment of Omphalitis” Arch Dis. Child. Fetal Neonatal Ed. 91:F91-F104, 2006
14) Mullany, L.C. “Topical Applications of Chlorhexidine to the Umbilical Cord for Prevention of Omphalitis and Neonatal Mortality n Southern Nepal: a Community-based, Cluster-randomized Trial” Lancet 367:910, 2006
15) Hseih, W.S. et al “Neonatal Necrotizing Fasciitis: A report of Three Cases abd Review of the Literature” Pediatrics103:e53, 1999
16) Iacono, G. “Red Umbilicus”:a Diagnostic Sign of Cow’s Milk Protein Intolerance. J. Ped.Gastro. And Nutr. 42:531-534, 2006
17) Burd R.S. et al “Evaluation and Initial Management of Miscellaneous Pediatric Surgical Problems”Pediatric Annals30:752-759, 2001