Ernesto Miranda-Cervantes, MD, Francisco C Sanchez-Garcia, MD, Mauricio Castano-Eguia, MD, Marco Juarez-Parra, MD, Aurora Guillen-Graf, Ulises Caballero-DelaPena, MD, Berenice Medina-Ortiz. Christus Muguerza Hospital Alta Especialidad / UDEM
INTRODUCTION: The urachus is a structure that connects the bladder dome with the umbilicus. A urachal cyst occurs when both ends are obliterated but the central portion remains patent. This types of cysts usually remain asymptomatic, and do not require medical treatment unless they become infected. The most frequent clinical findings are infraumbilical painful mass, umbilical discharge, and sepsis.
CASE REPORT: An 8-month-old male, product of a twin pregnancy (dichorionic-diamniotic) obtained at 35.6 weeks of gestation due to preterm labor, with history of hydrocephalus and myelomeningocele treated with corrective surgery and peritoneal shunt valve placement at day 2 of extra uterine life.
He arrived to the ER with a 4-day history of vomiting and decreased stool consistency; one-day prior admittance he progressed with bilious emesis, hyporexia, irritability, hyporeactivity, and mild abdominal distension.
Physical exam of the abdomen revealed absence of peristalsis, a 2×2 cm peri-umbilical mass that was tender to palpation, no purulent or hematic discharge was observed.
A complete blood cell count revealed a hemoglobin of 8.1g/dl, hematocrit of 24.2%, a leukocyte count of 19 550/mm3, and a platelet count of 694 104/mm3. C- reactive protein was elevated at 246.2 mg/dl. The remaining laboratory findings were within normal range. A plain abdominal film revealed intestinal dilation of up to 3 cm and scarce distal gas in relation of an obstructive process. (Figure 1)
A nasogastric tube was placed and kept in observation for 12 hours without improvement. Upon surgical consultation, a diagnostic laparoscopy was planned.
During the procedure, and infected urachal cyst was found along with free purulent fluid and distended small bowel loops (Figure 2,3). Intestinal loops were freed and the urachal remnant was ligated at the vesical dome. (Figure 4)
CONCLUSION: The urachus and umbilical arteries lie in a extraperitoneal fascial plane, and it is extremely difficult for an urachal abnormality to produce intra-abdominal symptoms. Urachal cysts causing intestinal obstruction are rare and diagnosis can be challenging, laparoscopy has proven to be safe and feasible in the pediatric population.
