Umbilical Granuloma

A mother brought her 6-week-old daughter to the office for a well-baby examination. The girl had been born by spontaneous vaginal delivery at term. There had been no complications during the delivery, and the neonate was feeding well and gaining weight appropriately. The girl’s umbilical stump had fallen off approximately 3 weeks after birth, and afterward the mother had noticed a red, moist growth at the site.

Physical examination. The patient was afebrile at presentation. Abdominal examination findings were significant for a moist, soft, red, pedunculated umbilical mass at the base of the umbilicus. No drainage, foul discharge, or purulence was present. The surrounding skin was not red, warm, or swollen. Based on her presentation, the girl received a clinical diagnosis of umbilical granuloma.

Discussion. Umbilical granulomas are the most common cause of umbilical mass in neonates. They become apparent after the umbilical stump separates.¹ They often are smooth and pedunculated but can have an irregular surface. They usually are 3 to 10 mm in size, beefy red in appearance, and soft, moist, and friable. Formation of granulation tissue is part of the normal process of wound healing, but in the case of umbilical granulomas, overgrowth of granulation tissue occurs; the tissue contains fibroblasts and capillaries. It commonly is treated with applications of topical 75% silver nitrate. However, multiple office visits sometimes are required to achieve the best results, and a risk of chemical burns or staining of the surrounding skin exists. Recent literature supports a double-ligature technique, which is simple to perform and provides good cosmetic and functional results with minimal complications.² Ultrasonography of the abdomen may be necessary if suspicion exists that the mass may represent omphalomesenteric or urachal abnormalities.

Differential diagnosis. Umbilical polyps are rare but can appear very similar to umbilical granulomas. They are bright red, firm nodules in the umbilical dimple.³ They are embryologic remnants of intestinal epithelium or uroepithelium, but they do not communicate with the bladder or intestines. Umbilical polyps do not respond to silver nitrate and must be surgically removed. If a polyp is diagnosed, further evaluation for associated embryonic anomalies should be performed.⁴

Congenital hemangiomas are flat or raised noncancerous tumors that are purple or red and usually have lighter-colored surrounding skin. They often are found on the head, neck, or limbs but also can appear on the trunk. They comprise many thin-walled blood vessels and almost always present at birth. They may rapidly involute during the first year of life or remain permanent.⁵

Urachal cyst is a remnant and incomplete closure of the urachus after birth. The urachus normally involutes and forms a fibrous cord between the umbilicus and the bladder, the median umbilical ligament. Closure occurs at the bladder and the umbilicus, but the mid-duct remains patent, resulting in a cyst.³ Children with a urachal cyst have a mass below the umbilicus and present after evidence of infection—a painful, swollen area with erythema. Upon diagnosis, a surgical consult is warranted.

An umbilical cord hernia is actually a small omphalocele. It is an umbilical defect in which incomplete closure of the abdominal wall allows intestinal contents to herniate and remain covered within the Wharton jelly and abdominal viscera at the base of the umbilical cord. This congenital anomaly is present at birth. Umbilical cord hernias and omphaloceles require prompt surgical closure to avoid intestinal damage and further complications.⁶

References:

1. Donlon CR, Furdon SA. Part 2: assessment of the umbilical cord outside of the delivery room. Adv Neonatal Care. 2002;2(4):187-197.
2. Lotan G, Klin B, Efrati, Y. Double-ligature: a treatment for pedunculated umbilical granulomas in children. Am Fam Physician. 2002;65(10): 2067-2068.
3. Disorders of the umbilicus in infants and children: a consensus statement of the Canadian Association of Paediatric Surgeons. Paediatr Child Health. 2001;6(6):312-313.
4. Swanson DL, Pakzad B. An umbilical polyp in an infant. Cutis. 2005;76(4): 233-235.
5. Nasseri E, Piram M, McCuaig CC, Kokta V, Dubois J, Powell J. Partially involuting congenital hemangiomas: a report of 8 cases and review of the literature. J Am Acad Dermatol. 2014;70(1):75-79.
6. Cizmeci MN, Kanburoglu MK, Akelma AZ, Tatli MM. Do not overlook an umbilical cord hernia before clamping. Eur J Pediatr. 2013;172(8):1139.