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LETTER TO THE EDITOR Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 2  |  Page : 257-258
Spontaneous rupture of an umbilical hernia


Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi Anambra State, Nnewi-Nigeria, Nigeria

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Date of Web Publication14-Oct-2011
 

How to cite this article:
Ekwunife OH, Osuigwe A N. Spontaneous rupture of an umbilical hernia. Afr J Paediatr Surg 2011;8:257-8

How to cite this URL:
Ekwunife OH, Osuigwe A N. Spontaneous rupture of an umbilical hernia. Afr J Paediatr Surg [serial online] 2011 [cited 2019 Sep 20];8:257-8. Available from: http://www.afrjpaedsurg.org/text.asp?2011/8/2/257/86081
Sir,

Umbilical hernia is one of the commonest problems affecting children. It is the commonest of the childhood hernias. [1],[2] It is estimated that one out of every six children has umbilical hernia. [3] Male and females are equally affected. It is commoner in the blacks, especially in prematurely born babies. Most (75%) of the affected infants weigh less than 1.5 kg. [1]

Development of umbilical hernia is believed to have a molecular basis, as genetic heterogeneity accounts for the persistence of the ring after cord separation. [4] The natural course of umbilical hernia is to close spontaneously. Only about 10% of non-corrected cases persist into adulthood. [1] Complications were thought to be rare, but report by Ameh et al., suggested a higher complication rate in Africans. [2]

Spontaneous rupture with evisceration in children is rare, [2],[5],[6],[7] with only 18 reported cases worldwide. Nine of these (including the current case) occurred in black Nigerians.

We report a five-week-old previously healthy male child with a spontaneous rupture of his umbilical hernia with evisceration. The five-week-old term male infant presented to us via the children's emergency room with a six-hour history of protrusion of the intestines through the umbilicus. The mother discovered the protrusion of the intestines from the umbilicus on lifting the child from his sleeping prone position. The mother complained that the child frequently suffered from abdominal "colic", for which she has been administering oral herbal medications as well as laying the child prone frequently.

There was no preceding history of cough, or excessive straining during micturition or defecation. There was no prior change in bowel habit, abdominal swelling or vomiting, no previous ulceration of umbilicus. Umbilical swelling was noticed two weeks after the stump fell off on the seventh day of birth without any feature of infection.

The family history was unremarkable. Examination revealed a calm 3.8-kg baby with no clinical evidence of umbilical infection or trauma.

Following resuscitation and initial care, the gut was irrigated with warm isotonic saline. The defect was widened transversely. Intraoperative findings include a 25-cm loop of eviscerated small intestine protruding through the apex of the umbilicus with multiple subserosal haematoma. The fascial defect was 1.5 cm and smooth. Although the mesentery was oedematous, the gut was viable. The gut was returned into the abdomen and the fascial defect closed primarily.

He subsequently developed peritonitis and was re-explored on the fourth postoperative day. The intraoperative findings were two perforations, 5 cm apart, on the anti-mesenteric border of the small intestine. Resection of the affected part and an ileoileal anastomosis was done. Subsequent recovery was uneventful. Eighteen months on follow up, the child has remained healthy.

Umbilical hernia results from an imperfect closure or inherent weakness of the umbilical ring. [8] Spontaneous closure of the defect due to continued narrowing of the ring is expected in most cases. The age of repair of umbilical hernia is controversial, though the majority accepts elective repair after four to five years. [2],[6],[9],[10] Hernia defect with diameter greater than 1.5 cm or hernias in children above fiveyears of age are not likely to close spontaneously, although continued closure of the ring up to 14 years of age has been reported. [11]

Spontaneous rupture of umbilical hernia is rare despite the high incidence of umbilical hernia. Umbilical sepsis usually precedes umbilical rupture in children. [2],[5],[9],[12],[13],[14] The sepsis most probably weakens the umbilicus, increasing the risk of rupture. Other possible causes of rupture include excessive coughing due to bronchitis, [14] forceful bouts of vomiting, [15] positive pressure ventilation, [16] intestinal obstruction secondary to intussusception [2] and obstructed umbilical hernia, all of which would increase the intra-abdominal pressure. [17]

The intestinal perforation in the index case is attributed to ischemic changes arising from the tight neck of the hernia.

In conclusion, spontaneous rupture occurs more commonly in infants. Umbilical sepsis, damage to the umbilical skin, increased intra-abdominal pressure and defect size greater than 1.5 cm are important identifiable risk factors.

 
   References Top

1.Garcia VF. Umbilical hernia and other abdominal wall hernias. In: Ashcraft KW, editor. Pediatric Surgery. Philadelphia: Saunders; 2000. p. 651-3.  Back to cited text no. 1
    
2.Ameh EA, Chirdan LB, Nmadu PT, Yusufu LM. Complicated umbilical hernias in children. Pediatr Surg Int 2003;19:280-2.  Back to cited text no. 2
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3.Katz D. Evaluation and management of inguinal and umbilical hernias. Pediatr Ann 2001;30:729-35.  Back to cited text no. 3
    
4.Ciley RE. Disorders of umbilicus. In: Grosfeld J, editor. Paediatric Surgery. Philadelphia: Mosby; 2006. p. 1143-55.  Back to cited text no. 4
    
5.Singh UK, Singh S, Ojha P, Kumar R. Spontaneous rupture of an Umbilical hernia in an infant. Indian Pediatr 2000;37:341-2.  Back to cited text no. 5
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6.Durakbasa CU. Spontaneous rupture of an infantile umbilical hernia with intestinal Evisceration. Pediatr Surg Int 2006;22:567-9.  Back to cited text no. 6
[PUBMED]    
7.Harding-Jones D, Robson P. Rupture of an infantile umbilical hernia. Br Med J 1965;5433:498-9.  Back to cited text no. 7
    
8.Fonkalsrud EW, Coran AG, Caldamone AA, Schwartz MZ, Hirschi RB, Borer JG, et al. Principles of Paediatric Surgery. 2 nd ed. Missouri: Mosby; 2004. p. 432-6.  Back to cited text no. 8
    
9.Bain IM, Bishop HM. Spontaneous rupture of an infantile umbilical hernia. Br J Surg 1995;82:35.  Back to cited text no. 9
[PUBMED]    
10.Brown RA, Numanoglu A, Rode H. Complicated umbilical hernia in childhood. S Afr J Surg 2006;44:136-7.  Back to cited text no. 10
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11.Meier DE, Ola Olorun DA, Amodele RA, Nkor SK, Tarpley JL. Incidence of umbilical hernia in African children: Redefinition of ''Normal'' and reevaluation of indication for repair. World J Surg 2001;25:645-8.  Back to cited text no. 11
    
12.Teshiba R, Yamanouchi T, Yakabe S. A case report of spontaneous rupture of an infantile umbilical hernia. Jpn Soc Pediatr Surg 2008;44:595-8.  Back to cited text no. 12
    
13.Chatterjee SK. Spontaneous rupture of umbilical hernia with evisceration of small intestine. J Indian Med Assoc 1972;59:287.  Back to cited text no. 13
[PUBMED]    
14.Ahmed A, Ahmed M, Nmadu PT. Spontaneous rupture of infantile umbilical hernia: Report of three cases. Ann Trop Paediatr 1998;18:239-41.  Back to cited text no. 14
[PUBMED]    
15.Bode CO, Adeyemi SD. Spontaneous Umbilical Rupture: A report of two cases. Niger J Surg 1997;4:17-8.  Back to cited text no. 15
    
16.Weik J, Moores D. An unusual case of umbilical hernia rupture with evisceration. J Pediatr Surg 2005;40:E33-5.  Back to cited text no. 16
    
17.Jamabo RS. Spontaneous rupture of an umbilical hernia with evisceration of small intestine In a 16-year-old girl. Port Harcourt Med J 2007;1:119-20.  Back to cited text no. 17
    

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Correspondence Address:
Okechukwu Hyginus Ekwunife
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi Anambra State, Nnewi-Nigeria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.86081

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