Case Report

Shafiq Ahmad Chughtai, Faisal Murad, Atif Khan, Asif Zafar Malik
Surgical Unit II, Holy Family Hospital, Rawalpindi.

INTRODUCTION history of passage of worms from the
umbilicus twice in this period. She did not give
Umbilicus is the central abdominal scar and history of any urinary problem or abdominal
the thinnest part of the anterior abdominal complaint before surgery.
wall. Umbilical discharge is the hallmark of At presentation, her general physical
underlying umbilical pathology. Few of the examination showed a female with average
causes of umbilical discharge include built, pulse of 120/min, temperature of 102 F,
infection, granuloma, dermatitis, calculus, tachypnic with respiratory rate of 26 per
pilonidal sinus and umbilical fistula. Umbilical minute and blood pressure of 130/80 mm Hg.
fistula can be acquired or congenital. A slow A transverse incision was seen at the level of
leak from any viscus is liable to track to the umbilicus closed primarily without any signs
surface at this point. Variety of congenital of inflammation. Abdominal examination was
anomalies exist like patent vitello intestinal suggestive of generalized peritonitis.
duct (VID) and patent urachus which can Her emergency investigation showed HB of 12
present as umbilical fistula thus it is said that g/dl, TLC of 16,000 per micro liter, urea 48
umbilicus is one of the commonest site for mg/dl, creatinine 0.8 mg/dl. Serum
fistulous communication. electrolytes were normal. USG abdomen/
An unusual case of umbilical discharge in an pelvis showed free fluid in moderate amount.
adult female is being reported secondary to Previous record showed normal base line,
patent VID. Failure to identify the tract lead to stool RE positive for ascaris lumbricoides,
increased morbidity in this patient. normal USG and barium studies. Sinogram
failed because the radiologist failed to identify
CASE REPORT external umbilical opening.
After adequate optimization, she was explored
36 years old female, post operative case of in emergency via a midline incision. Pre
omphalectomy for umbilical discharge, operatively we found 500 cc turbid fluid and a
presented to us from periphery with meckel’s diverticulum having a thin blind tract
generalized abdominal pain, 3 days after attached to it. There was no abnormality
surgery. Pain was of gradual onset, all over detected in rest of the gut and bladder was
abdomen, moderate intensity and was found to be normal.
associated with vomiting. In her past history Excision of the tract, resection of the ileum
she was having discharge from the umbilicus, containing the meckel’s diverticulum followed
off and on for the last 2 years. Discharge by primary anastamosis was done. Keeping in
usually occurred once or twice a week, was mind passage of worms from the umbilicus
scanty in amount, brown in colour and used to and development of peritonitis following
stain her clothing. The discharge was not foul omphalectomy, we made a final diagnosis of
smelling and was associated with occasional umbilical enterocuteneous fistula due to
itching around umbilicus. She also gave patent vitello-intestinal duct which was
missed in the initial surgery. Post operatively,
Corresponding Author: she made an uneventful recovery and was
Shafiq Ahmad Chughtai, discharged on 8th post operative day. Her
Surgical Unit II, histopathology showed meckel’s diverticulum
Holy Family Hospital, Rawalpindi. containing ectopic pancreatic mucosa.

42 JUMDC Vol. 2, Issue 1, Jan-Jun 2011

attachment of infants) revealed that 65 cases of patent VID embryological origin exists in 15% and 2% of have been reported in Japan. sub acute intestinal the most common VID anomaly. MURAD F. The larvae of Ascaris lumbricoides cause pulmonary Umbilical discharge occurs due to many symptoms and the adult worms cause reasons. Ten out of 55 patients died worm) infestation and thus it is the most (18.0%). VID is very unusual. VID obstructive jaundice due to adult worms associated anomalies can cause discharge traveling up into the common bile duct. et al. Many cases have been reported in the intussusceptions. The largest vitellointestinal duct and the present with possible number of patients. Jan-Jun 2011 43 . 2. A colonic tissue may also be found.2%).8%) were premature.2%) under went surgery. This is most commonly diameter was 1. Ectopic gastric mucosa gastric mucosa.2 relatively high incidence of prolapse of ileum Almost one third of world population has was found. lower GI bleeding.8 cm and meckel’s diverticulum.1 cm. Issue 1. Ten of the 36 embryological origin have a patent infants (27. CONGENITAL UMBLICAL FISTULA DISCUSSION common intestinal nematode. cases (93. duodenal or was found in 3 out of 30 cases (10. cholangitis and even prevalence of 2% of the population. The these patients with the attachment of male/female ratio was 2. In gastrointestinal tract. 55 out of 59 feacal umbilical fistula in neonatal age group. intestinal obstruction and literature concerning the VID and associated volvulus. The In 70% of the cases ectopic tissue is found in average length of VIDs was 3. CHUGHTAI SA. Meckel’s diverticulum is it can cause malnutrition. 8 of these had a prolapse of the JUMDC Vol. A review of the literature (in ended in 85% of cases. pancreatitis.3 from the umbilicus.8:1.8%). Meckel's diverticulae are blind anomalies. present in 28 out of 53 patients Ascaris lumbricoides (also known as round (52. but in adult population the patent intestinal symptoms. with a obstruction. but pancreatic.

was an additional clue in our case which was Romanian J Morphology & Embryology overlooked because of normal Barium studies 2010. 49-70. mesenteric duct in an adult without Histry of passage of worms from the umbilicus meckel’s diverticulum or vitelline cyst. Round worm infestation is very common in Indian children. 44 JUMDC Vol. 5(2): 116-23. Essential umbilical fistula secondary to a patent VID Surgical Practice Higher Surgical Training presenting in adult population.5 Hernia. fecal discharge at umbilicus. meckel's diverticulum has male predominance 2. et al. Indore. Nassir A. Omphalomesenteric duct intestinal attachment revealed a band passing malformations. In our case.4 associated anomalies so that the patient can Patent VID is not an infrequent abnormality in be saved from developing peritonitis children. Datta PK. Acta Paediatr Acad Sci Hung. adult years as well. Bailey and Love’s Short undergraduate students in the Department of Practice of Surgery 25th ed. Investigation is of limited value and high index of suspicion with Accepted for publication: April 2011 careful per operative evaluation is mandatory. Mahato. remnant of the vitellointestinal duct was 3. ABBREVIATIONS Patients with patent VID and round worm Vitello intestinal duct (VID) emerging from the umbilicus is unique presentation. 23(11): observed from the exterior. 527-68. 7. In General Surgery 4th ed. Mahato NK. the patient was a female and vermiform appendix.4 The patent VID with 984-85. Umbilical discharge has many reasons. Kumar R. In: Patent VID becomes symptomatic early in life. a rare but important cause of umbilical discharge can present at any age and may remain asymptomatic for a Submitted for publication: Feb. through the umbilicus. A case has been reported in a 2- REFERENCES year-old boy with patent VID who presented with a history of round worms coming out 1. This is true 19(2): 113-23. symptoms may persist through Surgery 25th ed. fibrous University Press Inc.7 1061-62. 2002. 2. but 6. Bulstrode CJK. Kingsnorth AN. India. In view of the high mortality rate of Treatment should aim at excision of the tract patients with a prolapse of the ileum and the and inspection of bowel to rule out meckel’s strong possibility of intestinal obstruction. Jan-Jun 2011 . management of such patients. Williams NS. Moore TC. Moosa AR (edi). years) during routine dissection for Connell PR (edi). fibrous omphalo- not foul smelling and patient is an adult. cysts and other patent VID merits surgical resection. The 4. Patent VID. 2011 very long period of time. diverticulum. 1988. Szemledy F. and USG.K. Unusual anterior abdominal part exhibited an extra- Presentation of patent vitellointestinal duct peritoneal extension towards the umbilicus. Steele RJC. Bailey & Love’s Short Practice of treatment. Pinter A. Umbilicus and abdominal wall. Lal P. Surgery in the detected in an adult male cadaver (about 60 tropics. Semin Peadiatr Surg. bands. Hodder Arnold 2008. Sciences (SAIMS). In: Williams NS. Pilaszanovich I. Oxford In a case report by N. Connell PR mostly in first two years and without (edi). CHUGHTAI SA. Obliterated. 51(1): 195-97. The most common presentation is of subsequently. Giorgobiani G. The attachment on the 5. MURAD F. even when the discharge is scanty in amount. Surendran N. Bulstrode CJK. Bennett DH. In: Cuschieri A. J Paediatr Surg. 1978. Bakshi SD. the mesentery. Issue 1. Disorders of small intestine of 9:16. and we have failed to find any case of fecal Steele RJC. beyond the loop of the distal ileum towards 1996. CONGENITAL UMBLICAL FISTULA ileum. Hodder Arnold Anatomy at Sri Aurobindo Institute of Medical 2008. with round worms emerging from the The umbilicus was absolutely normal when umbilicus. one should never forget the possibility of Remanants of vitelline duct: analysis of 66 umbilical communication with the gut in the cases.