Photo Essay

An Atlas of Lumps and Bumps: Part 24

Alexander K.C. Leung, MD1—Series Editor • Benjamin Barankin, MD2 • Joseph M Lam, MD3 • Andrew A. H. Leung, BSc4 • Alex H.C. Wong, MD5

Volume 63 - Issue 2 - February 2023
Umbilical Hernia

An umbilical hernia results from imperfect closure or weakness of the umbilical ring.1,2 Umbilical hernias are found in 15% to 23% of newborn infants.3 The incidence is affected by gestational age, birth weight, age of the child, race, and coexisting disorders.4 Umbilical hernias are about six to 10 times more common in Black individuals than White individuals.2,5 They are also more common in low-birth-weight and premature infants.5 The sex incidence is approximately equal.6

Most umbilical hernias are sporadic and occur as isolated findings in otherwise healthy infants. Umbilical hernias occur with increased frequency in patients with Beckwith-Wiedemann syndrome, Down syndrome, trisomy 13, trisomy 18, congenital hypothyroidism, mucopolysaccharidosis, and cirrhosis of the liver with ascites.2,5

Classically, an umbilical hernia presents as a soft, skin-covered swelling that protrudes through the fibrous ring at the umbilicus.2 (Figure 1)

Figure 1 An umbilical hernia in an infant is shown.

The umbilical bulge becomes more apparent during episodes of crying, coughing, or straining and is easily capable of being reduced.2 The content usually consists of a piece of small intestine and, sometimes, omentum. The condition is usually asymptomatic and recognized in the neonatal period.2  

Complications, such as incarceration of intestine or omentum, strangulation, perforation of the intestine, and rupture with evisceration, are rare in children.1,2,6-8 The risk of complications varies greatly between populations worldwide and is much higher in adults.7,9 For young women with persistent umbilical hernia, the umbilical defect may enlarge and become symptomatic during pregnancy.2 Most umbilical hernias resolve spontaneously, usually within the first 2 years of life, if not the first year.2 Of the umbilical hernias not repaired in childhood, approximately 10% persist into adulthood.10

Paraumbilical Hernia

A paraumbilical hernia is due to a defect in the linea alba close to the umbilicus. Unlike an umbilical hernia, a paraumbilical hernia does not protrude through the umbilical area. Rather, it protrudes just above or below the umbilicus (Figure 2). Unless complicated, a paraumbilical hernia can be reduced manually and asymptomatic.

 

Figure 2. A paraumbilical hernia in an adult male is shown.

Although the defect in the linea alba is congenital, a paraumbilical hernia may not be noticeable until later in life when abdominal contents herniate through the defect and presents with a visible lump on the abdominal wall. Paraumbilical hernias are more common in adults than in children.

The female to male ratio is about 5:1.11 The condition is more common in White individuals, those with obesity, and in those with weak abdominal muscles.12 A paraumbilical hernia poses a risk of incarceration and strangulation.13-15 Omentum, small bowel, and large bowel are the usual content.11 Occasionally, the content consists of an appendix or a Meckel’s diverticulum.15,16

The diagnosis of paraumbilical hernia can usually be made clinically unless the hernia sac is small or the patient’s body habitus interferes with adequate palpation. High-resolution ultrasonography is an efficient tool for detecting the presence of a paraumbilical hernia and accurately verifies not only its content but also possible associated complications.13 A recent onset of a paraumbilical hernia in the elderly is a possible sign of internal malignancy.17

A paraumbilical hernia does not close spontaneously.12 Elective herniorrhaphy is advisable because of the recognized risk of complications.

AFFILIATIONS:
1Clinical Professor of Pediatrics, the University of Calgary; Pediatric Consultant, the Alberta Children’s Hospital, Calgary, Alberta, Canada
2Dermatologist, Medical Director and Founder, the Toronto Dermatology Centre, Toronto, Ontario, Canada
3Associate Clinical Professor of Pediatrics, Dermatology and Skin Sciences, the University of British Columbia, Vancouver, British Columbia, Canada.
4Faculty of Medicine, St. George’s University, Grenada
5Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada

CITATION:
Leung AKC, Barankin B, Lam JM, Leung AAH, Wong AHC. An atlas of lumps and bumps, part 24. Consultant. 2023;63(2):e11. DOI: 10.25270/con.2023.02.000002.

DISCLOSURES:
Dr Leung is the series editor. He was not involved with the handling of this paper, which was sent out for independent external peer review.

CORRESPONDENCE:
Alexander K. C. Leung, MD, #200, 233 16th Ave NW, Calgary, AB T2M 0H5, Canada (aleung@ucalgary.ca)

EDITOR’S NOTE:
This article is part of a series describing and differentiating dermatologic lumps and bumps. To access previously published articles in the series, visit https://www.consultant360.com/resource-center/atlas-lumps-and-bumps.

References

 

  1. Halleran DR, Minneci PC, Cooper JN. Association between age and umbilical hernia repair outcomes in children: A multistate population-based cohort study. J Pediatr. 2020;217:125-130.e4. doi: 10.1016/j.jpeds.2019.10.035.
  2. Leung AK. Umbilical hernia. In: Leung AK. Ed. Common Problems in Ambulatory Pediatrics: Specific Clinical Problems, Volume 1. New York: Nova Science Publishers, Inc. 2011, pp23-26.
  3. Zens TJ, Rogers A, Cartmill R, Ostlie D, Muldowney BL, Nichol P, et al. Age-dependent outcomes in asymptomatic umbilical hernia repair. Pediatr Surg Int. 2019;35(4):463-468. doi: 10.1007/s00383-018-4413-3.
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  11. Daoud FS. Incarcerated endometriotic ovarian cyst within paraumbilical hernia. J Obstet Gynaecol. 2005; 25(8):828-829. doi: 10.1080/01443610500338347.
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  13. Bedewi MA, EI-Sharkawy MS, AI Boukai AA, AI-Nakshabandi N. Prevalence of adult paraumbilical hernia. Assessment by high-resolution sonography: a hospital-based study. Hernia. 2012; 16(1):59-62. doi: 10.1007/s10029-011-0863-4.
  14. Yau KK, Siu WT, chan KL. Strangulated appendix epiploica in paraumbilical hernia: preoperative diagnosis and laparoscopic treatment. Surg Laparosc Endosc Percutan Tech. 2006; 16(1):49-51. doi: 10.1097/01.sle.0000202199.82193.84.
  15. Zormpa A, Alfa-Wali M, Chung A. Appendicitis within the contents of an incarcerated paraumbilical hernia. BMJ Case Rep. 2019 Aug 10;12(8):e228915. doi: 10.1136/bcr-2018-228915.
  16. Kong V, Parkinson F, Barasa J, Ranjan P. Strangulated paraumbilical hernia - An unusual complication of a Meckel's diverticulum. Int J Surg Case Rep. 2012;3(6):197-198. doi: 10.1016/j.ijscr.2012.02.001.
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