|
 
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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 11
| Issue : 2 | Page : 145-151 |
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Umbilical granulomas and umbilical polyps: Comparative evaluation with silver nitrate cauterization and surgical excision
Rahul Gupta, Shyam Bihari Sharma, Ram Babu Goyal
Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
| Date of Submission | 13-Mar-2022 |
| Date of Decision | 10-Jul-2022 |
| Date of Acceptance | 19-Jul-2022 |
| Date of Web Publication | 22-Aug-2022 |
Correspondence Address:
Rahul Gupta
Associate Professor, Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjhs.sjhs_34_22
Background: Umbilical granuloma (UG) and umbilical polyps (UPs) are the most common umbilical abnormalities in neonates, causing inflammation and drainage. Aims: The aim of this study was to compare the effectiveness of the technique of silver nitrate cauterization and surgical excision on both UG and UP in pediatric patients. Settings and Design: A prospective study on UG and UP was carried out in a high-volume tertiary care teaching institute from January 2015 to December 2020. Materials and Methods: The patients were randomly distributed by chit method into two groups: Group A treated with surgical excision and Group B treated with silver nitrate cauterization. Statistical Analysis: The unpaired Student's t-test was used to find the existence of any statistical significance between the parameters of the two groups. Results: There were 105 patients with 59 males and 46 females. There were 70 patients in Group A and 35 in Group B. Most of the patients in both Group A and Group B were between >1 and 3 months of age group. Blood mixed umbilical discharge was the most common complaint. There was complete resolution of symptoms in 100% of patients in Group A. In Group B, success with first attempt with cauterization was achieved in 20 (57.14%) patients and 12 (34.29%) patients after the second attempt. In Group B, successful management was achieved in 2 (5.71%) patients after the third attempt combined with double ligation. In 1 (2.86%) patient, there was an incomplete response to cauterization. Minimal perilesional burn (in the umbilicus) was observed in four cases, two each in the UG and UP groups. Conclusions: The technique of silver nitrate cauterization for both UG and UP is a simple, less expensive, and safe procedure in experienced hands. Most patients show complete responses at the first attempt. In others, complete resolution is accomplished at the second or third attempt. Surgical excision should be performed in cases with an incomplete response and larger lesions.
Keywords: Cauterization, silver nitrate, surgical excision, umbilical granuloma, umbilical polyp, umbilicus
How to cite this article:
Gupta R, Sharma SB, Goyal RB. Umbilical granulomas and umbilical polyps: Comparative evaluation with silver nitrate cauterization and surgical excision. Saudi J Health Sci 2022;11:145-51 |
How to cite this URL:
Gupta R, Sharma SB, Goyal RB. Umbilical granulomas and umbilical polyps: Comparative evaluation with silver nitrate cauterization and surgical excision. Saudi J Health Sci [serial online] 2022 [cited 2023 Jun 10];11:145-51. Available from: https://www.saudijhealthsci.org/text.asp?2022/11/2/145/354160 |
| Introduction | |  |
An umbilical granuloma (UG) is the most common (1 in 500 newborns) umbilical abnormality in the neonate, encountered after separation of the umbilical cord.[1],[2] It is a benign overgrowth (and not a congenital abnormality) of granulation tissue during the healing process of the umbilicus [Figure 1].[3],[4] UG is defined as a small (1–10 mm) soft/friable/fleshy, moist, nontender, soft pink or red lesion at the center of the umbilicus.[1],[2] Umbilical polyps (UPs) are remnants of omphalomesenteric duct enteric mucosa at the umbilicus.[5] Both UG and UP are associated with frequent visits to the clinicians as they secrete small amounts of clear or yellow fibrinous exudate. | Figure 1: Clinical photographs showing umbilical granuloma (a1, b1, c1, and d1) and post-silver nitrate cauterization (a2, b2, c2, and d2); intraoperative photographs showing surgical excision of umbilical granuloma (e1) and umbilical granuloma specimen (e2)
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Various authors recommend various modalities ranging from the application of a conservative approach with chlorhexidine solution, alcoholic wipes, common salt application, and topical antibiotics to chemical cauterization with silver nitrate or copper sulfate, cryotherapy, and surgical excision.[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19] Each treatment modality has its merits and demerits. A series of patients have been reported in the past with burns to the anterior abdominal wall after silver nitrate cauterization.[6],[20],[21] These chemical burns have discredited the use of silver nitrate in these patients. Furthermore, as per one study, steroid (topical clobetasol propionate) cream has been recommended as an alternative to silver nitrate cauterization.[22] Surgical excision of the lesions carries the additional risk of general anesthesia, though it is the procedure of choice in recurrent or intractable cases.[12] Thus, there is an absence of consensus regarding the management modality of UG and UP in the literature.[6],[7],[8],[9],[10],[11],[12] We have decades of safe experience using silver nitrate cauterization on an outdoor basis for both UG and UP. This precipitated us to conduct the present study using both surgical excision and silver nitrate cauterization. The objective of the study was to analyze the outcomes of UG and UP managed with chemical cauterization with silver nitrate and surgical excision in our high-volume tertiary care teaching institute.
| Materials and methods | | |
This prospective study was conducted in the pediatric surgery department of a tertiary care teaching institute (India) over 6 years from January 2015 to December 2020. All pediatric patients presenting with UG and UP were studied.
Ethics
Approval was taken from the concerned authority before the commencement of the study.
Inclusion criteria
All pediatric patients <12 years of age presenting with UG and UP were included in the study.
Exclusion criteria
(1) Actively bleeding UG with hemodynamic instability and (2) UP with underlying associated vitellointestinal duct (VID) anomalies were excluded from the study.
A thorough clinical evaluation of all the patients was performed. In all patients, baseline blood investigations including complete blood counts and renal and liver function tests were performed. Abdominal ultrasound was done to detect any associated abdominal pathology. Echocardiography was done in patients suspected to have cardiac anomalies. Routine use of echocardiography was not considered due to resource limitations. The details were entered in the pro forma.
Parental informed consent form for study
Informed written consent was obtained from the patient's parents/guardians about the study. The parents explained the purpose of the study and the physical risks associated with both the procedures.
Management
The patients were randomly distributed by chit method into two groups: Group A treated with surgical excision and Group B patients treated with silver nitrate cauterization. Patients in Group A were admitted after preanesthesia evaluation; patients were shifted to operation theater, and under general anesthesia, excision of the lesion (UG/UP) was performed. All the operations were performed either by a pediatric surgeon or a senior resident under the direct supervision of a pediatric surgeon. The patients were assessed, following discharge to 6-month follow-up.
Group B patients were treated with silver nitrate cauterization. Umbilicus was cleaned with normal saline and then the involved area was dried. The skin surrounding the umbilicus was applied with either petroleum jelly or soft paraffin. Tailor-made small-sized drapes/gauze pads were placed to expose only the umbilicus. The base of UG or UP was exposed and silver nitrate crystal was carefully selected and placed over the base for 30 s and a maximum of 60 s. The area was kept exposed for a few minutes. A dry small dressing was placed, and re-inspection was performed after 30 min to record complications like periumbilical burns.
All the medical records were carefully recorded in a predesigned pro forma, and the information obtained was analyzed according to the objectives of the study. Charts were prepared and statistical data analysis was obtained with SPSS Statistics for Windows, version x.0 (SPSS Inc., Chicago, Ill., USA). The unpaired Student's t-test was used to find the existence of any statistical significance between the parameters of the two groups. P < 0.05 was considered significant statistically.
| Results | | |
There were 105 patients in the study with 70 patients in Group A and 35 in Group B [Table 1]. The measures of the central tendency of Group A and Group B are described in [Table 1]. The sex distribution and randomization of both UG and UP patients into Group A and Group B are shown in [Table 2]. The age distribution of patients in both Groups A and B is shown in [Table 2]. Most of the patients in both Group A and Group B were between >1 and 3 months of age group followed by >3–6 months of age group. | Table 1: Sex distribution, randomization, and measures of central tendency of patients into Group A and Group B
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There were 59 males and 46 females. The male-to-female ratio was 1.28:1. Most of the UG and UP patients were between >1 and 3 months of age group followed by >3–6 months of age group. The smallest patient in Group A and Group B was 10 days and 15 days, respectively, while the eldest patient in Group A and Group B was 8 years and 5 years, respectively. Clinically evident UG [Figure 1] was present in 58 and UP [Figure 2] in 47 patients. Similarly, the smallest patient in UG and UP was 10 days and 25 days, respectively, while the eldest patient in UG and UP was 7 years and 8 years, respectively. The mean, median, and mode values (measures of central tendency) of individual groups, UG and UP, are described in [Table 2]. | Figure 2: Clinical photographs showing umbilical polyp (a1, b1, and c1) and postsilver nitrate cauterization (a2, b2, and c2); intraoperative photographs showing surgical excision of umbilical polyp (d1 and e1) and umbilical polyp specimen (e2)
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 | Table 2: Sex and age distribution of both umbilical granuloma and umbilical polyp patients in Group A and Group B and also measures of central tendency of the data in our series
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The clinical presentations (chief complaint) of UG and UP are described in [Table 3]. Bleeding/oozing from the umbilicus was the most common (32) chief complaint in patients with UG, while umbilical discharge was the most common (19) chief complaint in patients with UP. Overall, blood mixed umbilical discharge was the most common complaint [Table 3]. In UG, there was a history of use of umbilical clamps in 100% (35) of patients. | Table 3: Clinical presentation and associated comorbidities in the present series; response assessment with chemical cauterization (Group B) in both umbilical granuloma and umbilical polyp
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The associated comorbidities in the present series are described in [Table 3]. Omphalitis was the most common (18) associated comorbidity. It was followed by anemia (8) due to continuous blood ooze from the lesion.
There was complete resolution of symptoms in 100% of patients in Group A. In Group B, overall, there were excellent responses in 20 (57.14%) patients with the first attempt with cauterization in both UG [Figure 1] and UP [Figure 2]. In 12 (34.29%) patients (UG and UP), there was complete resolution after the second attempt, while in 2 (5.71%) patients, a third visit to the clinic for cauterization was required for a complete response [Table 3]. In the latter patients (both large-sized UP ≈ 1 cm), additionally, double ligation of the lesion was performed. The lesion fell off after 1 week. In 1 (2.86%) patient, there was an incomplete response to cauterization due to a large-sized granuloma (1.5 cm). This patient was managed later with surgical excision.
In Group B, minimal perilesional burn (in the umbilicus) was observed in four cases, two each in the UG and UP groups. No other postoperative complications were observed in our patients. There were no recurrences in our series. Follow-up was done 6 months after discharge/last visit to the clinic.
| Discussion | | |
The umbilical cord normally separates within 7–14 days (range from 3 to 45 days) after birth.[7] After cord separation, there may be incomplete epithelialization over the fibromuscular ring of the umbilicus and an area of thick red tissue or granulation tissue is discernible. The normal granulation tissue of the resolving umbilical stump of a newborn baby after proper umbilical stump care should disappear by the 2nd or 3rd week of life. Thus, UG results as a consequence of overgrowth of true granulation tissue at the umbilicus, which has not yet epithelialized. It is devoid of nerves and pain receptors and usually has a short pedicle; occasionally, it is sessile.[2],[8] The natural regression of the untreated UG is not known to date.[3] We postulate that, after cord clamping (with plastic cord clamp), if there is improper cord cleansing or cord care, there would be increased inflammation at the umbilical stump. This is followed by lodgment and colonization of bacteria at the umbilical stump and then the growth of bacteria.[3],[4],[9] Due to these conglomerations of factors with underlying host factors, there is an augmentation of granulation tissue and granuloma formation [Figure 3]. Furthermore, the presence of the clamp itself prevents proper cleansing as the mother fears that the baby would feel pain if the clamp is handled. Similarly, the clamp may act as a lever and lead to recurrent injury at the cord stump and increased inflammatory response [Figure 4]. We have observed that sterilized linen thread with cord care is rarely associated with UG, as care is easy without a clamp in situ. | Figure 3: Inverted pyramid showing pathogenesis of umbilical granuloma formation following umbilical cord clamping
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 | Figure 4: Clinical photographs showing (a) umbilical cord clamp in situ with appropriate cord care (blue arrow). (b) Umbilical cord clamp with tied-up thread in situ with improper cord care; also, presence of pus at the base of the cord (red arrow) and with pus tract along the falciparum ligament. (c) Presence of two cord clamps in situ hampering cord care (white arrow), (d) umbilical granuloma visible after cord separation
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UPs are remnants of omphalomesenteric/VID enteric mucosa at the umbilicus.[5] It appears bright, red-colored, and covered with real epithelium [Figure 2]. Both UGs and UPs have similar symptoms and findings and pose a clinical and diagnostic challenge.[5]
UG and UP are usually located deep into the umbilical region and are difficult to locate without proper examination. It requires the use of forceps (instrumentation) or slight push on either side of the umbilicus to evert it and locate both the UG and UP and also to make the lesion easily approachable.[11] The surrounding skin is normal.[12]
Blood mixed umbilical discharge with or without swelling is seen with UG, while umbilical discharge with associated omphalitis is seen with UP. Both were common findings in our series [Table 3]. Both are similar in their presentation and location. Furthermore, they are difficult to distinguish clinically. UG was slightly more common in males in our series with 31 males and 27 females, M: F ratio of 1.15:1. According to previous studies, the incidence of UG is the same in both males and females.[13] The most common age group affected with UG in our series was between 1 and 3 months; it was a similar finding in a recent series with maximum cases in the second month of life.[13],[14] In the UP group, there were 28 males and 19 females, with M: F ratio of 1.47:1. Associated comorbidities (with both UG and UP) described in our series are rarely documented in the literature.[11],[12] In the present study, associated cardiac anomalies and umbilical hernia were also present.
Initial treatment of UG is conservative management with chlorhexidine, triple dye, alcoholic wipes, topical antibiotics, and povidone-iodine 5% solution.[13],[15],[16] Persistent UG beyond 2-month period would necessitate some form of treatment by a pediatric surgeon.[1] Various modalities of management of UG have been described in the literature, with each having its merits and demerits. The modalities are (1) chemical cauterization with silver nitrate or copper sulfate, (2) common salt application, (3) alcoholic wipes, (4) cryocauterization, (5) electric cauterization, (6) surgical excision, and (7) granuloma ligatures (double-ligature technique, etc.).[3],[8],[17],[18] Best method would be the one having a curative effect with minimal complications.
The common methods of chemical cauterization are the application of (1) copper sulfate crystals and (2) concentrated silver nitrate solution or 75% silver nitrate stick.[1] Silver nitrate has caustic as well as antiseptic effects, which are responsible for its therapeutic role. We are using small 3–5-mm-sized crystals for cauterization [Figure 5]. Before doing cauterization, it is imperative to carefully dry the umbilicus and remove the umbilical exudate to prevent the spread of the chemical agent. Application of either petroleum jelly or soft paraffin, as a protective barrier, periumbilically would prevent skin staining or chemical burn in case of accidental spillage. Usually, the procedure has to be repeated two to three times in subsequent clinic visits.[1],[12] | Figure 5: Photographs showing (a1) silver nitrate crystals and (a2) amber-colored bottle; (b) copper sulfate crystals, and (c and d) skin burns following spillage of silver nitrate and copper sulfate crystals; (e) patent VID, (f) cylindrical appearance and opening at the vertex in a patent VID, and (g) broader base in patent VID, VID: Vitellointestinal duct
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It was described earlier that UP does not respond to silver nitrate application, but according to our study, silver nitrate cauterization is effective for UP, except for large ≈ 1-cm-sized lesions.[19] In addition, in such cases, double ligation was performed. Larger UPs should be directly subjected to surgical excision.[19] This study is distinct from the previous reports where only UG was managed with silver nitrate cauterization, but here, the authors recommend it additionally for small-sized (<1 cm) UP as well.
Silver nitrate acts faster, within seconds, while copper sulfate is slow acting. Burns over the periumbilical skin (very painful) following spillage of silver nitrate or copper sulfate onto the surrounding tissues [Figure 5] have been reported.[6],[20],[21] Out of 35 patients in Group B, no patient suffered a periumbilical burn, but there were only 4 infants with minimal perilesional burn, limited inside the umbilicus.
The authors from the United Kingdom advised initial conservative treatment of UG with the use of alcoholic wipes (at home) followed by silver nitrate cauterization if there is no response.[6] The results of alcoholic wipes ranged from 53% to 67%.[21],[22],[23] Recently, the authors from Bangladesh recommended the use of common salt, as a simple, safe, cost-effective, and curative treatment for UG.[3] The shrinking effect of common salt on UG was first described by Schmitt in the year 1972.[24] In the present series, most patients (in both Groups A and B) were previously managed by different clinicians with diverse modalities of treatment like povidone-iodine, antibiotic/anti-inflammatory creams, ointment, and also common salt before seeking our appointment. We agree with the recommendation of Schmitt that, UG which does not get completely resolved within 3 weeks of treatment with common salt, pediatric surgical advice should be sought as early as possible.[24]
Cryocautery is complex and is associated with foul-smelling discharge.[25] Electrocautery is associated with high failure rates.[12] Pedicle type of UG could be managed with granuloma ligatures (double-ligature technique), but the deep-seated large/sessile type is difficult to manage with them.[12] Furthermore, the ligature may be painful and bleeding has been reported with its use. Furthermore, the technique is practically difficult in smaller lesions (UG); most of the UGs are small sized and therefore not the treatment of choice in all the patients.[12] In our series, we subjected two UP patients with a double-ligature technique after silver nitrate cauterization. The response was good. It takes 7–14 days for the granuloma/polyp to fall off from the umbilicus.[8] Surgical excision is the treatment of choice for UP and larger, intractable UG with complete resolution as seen in 100% of patients in Group A.[4],[10] There was surgical excision that may be combined with chemical cauterization of the umbilical base in relatively larger lesions with a wide base.[12] Finally, excisional biopsy is the definitive treatment and establishes the correct diagnosis.[12]
Kutin et al. suggested abdominal exploration in all patients with a UP to prevent possible complications (intestinal obstruction and/or intestinal bleeding related to associated VID anomalies (incidence of 56% on an abdominal cavity exploration).[26] When associated VID anomalies are suspected (on clinical history) preoperatively, UP should be inspected to exclude the presence of an opening at the vertex; an ultrasound or fistulogram should be performed.[5] A UG is usually globular in shape [Figure 2], while patent VID has a broader base with a cylindrical appearance [Figure 5]. UG is devoid of an opening at the vertex, while it is usually discernible on careful examination in a patent VID [Figure 5]. The size of patent VID is usually larger than 1 cm, and it is prone to reverse intussusception by the small bowel. The base of the umbilicus should be palpated and gently rolled between the fingers to ascertain the presence of the intestine when patent VID is suspected. Intraoperatively, postexcision, the base of UP must be probed to exclude a patent VID. According to the authors' experience, exploration of the peritoneal cavity in children with a UP does not seem to be necessary.[5] No patient (UP) in our series had patent VID.
In our study, complete response in Group B (silver nitrate cauterization) was appreciated with 91.43% (32/35) without any other therapy. In 2.86% (1), incomplete response was seen. The latter patient had large UG which was excised surgically. Furthermore, if the umbilical lesion is larger than 10 mm size, the likelihood of UP is present.[11]
We recommend that silver nitrate should be considered the treatment of choice for the patients with UG and UP, especially those who can easily access the medical facility. Surgical excision should be reserved for patients who do not completely respond to chemical cauterization after the second or third attempt.[19],[26] Early referral to a trained pediatric surgeon should be sought for correct clinical diagnosis and directing the therapy.
| Conclusions | | |
The technique of silver nitrate cauterization for both UG and UP is a simple, less expensive, and safe procedure in experienced hands. Most patients require management on an outpatient basis, with most patients showing complete response at the first attempt. In others, complete resolution is accomplished at the second or third attempt. The treatment obviates the need for admission and/or surgery in most of the patients. In a few patients, especially large-sized UP/UG, silver nitrate cauterization is unsuccessful and surgical excision is the treatment of choice. We recommend silver nitrate cauterization for UG and UP.
Acknowledgment
I am sincerely thankful to the faculty, residents, and nursing staff of the Department of Paediatric Surgery, SMS Medical College, Jaipur, for helping us in this endeavor.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]
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