A 40-year-old white American woman presented to primary care with a chief concern of nontraumatic umbilical bleeding that began 2 days prior; she woke up and noticed her shirt soaked in blood from her umbilicus. Upon applying pressure with a rag, she was able to stop the bleeding. The patient continued to experience intermittent umbilical bleeding associated with nonradiating periumbilical pain that was exacerbated by movement and associated with nausea and emesis. She had been seen for non-painful umbilical bleeding 5 years prior when she had been occasionally cleaning her umbilicus in the shower with a cotton swab and peroxide; this would sometimes leave small spots of blood on the cotton swab. At that time, no imaging was performed; she was prescribed bacitracin and told to apply Vaseline for what was presumed to be superficial irritation. She had no interim symptoms and discontinued cleaning her umbilicus with a cotton swab.
Past medical history included hypertension, gastroesophageal reflux disease, class III obesity with BMI 45, major depression, and generalized anxiety. Patient is a G1P1001. Surgical history was notable only for elective caesarean section 12 years prior without complications. The patient was divorced and worked in retail. She did not smoke, use illicit drugs, or drink alcohol. Family history included diabetes, Crohn’s disease, diverticulitis, and breast, lung, and prostate cancer. The patient was taking multiple long-term prescription medications, including losartan 50 mg tablet by mouth daily, propranolol 60 mg tablet by mouth twice daily, escitalopram 20 mg tablet by mouth daily, bupropion 450 mg tablet by mouth daily, gabapentin 300 mg capsule by mouth three times daily, norethindrone-ethinyl estradiol 1 mg–35 µg tablet by mouth daily, trazodone 100 mg tablet by mouth daily, and diclofenac 1% gel topically four times daily as needed.
On the day of presentation, the patient’s blood pressure was 125/81 mmHg with a pulse of 65 beats per minute. She was afebrile. Inspection revealed a non-distended abdomen and completely normal skin without erythema, fissuring, or visible discharge, though there was some dried blood. There was mild periumbilical tenderness with deep palpation. Deep palpation around the umbilicus produced a thin, watery, serosanguinous fluid directly from the umbilicus. The remainder of the physical examination including cardiac, pulmonary, and neurologic examinations, which were normal.
The patient was referred for CT of the abdomen/pelvis the same day, which revealed a small fat-containing umbilical hernia with a likely small area of fat necrosis just superior to the umbilical hernia (Fig. 1). Laboratory workup was notable for a mildly elevated high-sensitivity CRP at 13.8. The remainder of labs, including complete blood count (CBC) with differential, electrolytes, renal function, and liver function were within normal limits. No coagulation parameters were checked. Four weeks later, the patient underwent outpatient open umbilical hernia repair without mesh and umbilectomy with open wound packing. Dissection was performed down to the level of the fascia, and a 4.2-by-3.5-by-2.6 cm specimen consisting of the hernia sac and urachal remnants was excised and sent for pathologic interpretation. No cultures were sent since there was low suspicion for infection. She had complete resolution of symptoms and bleeding on follow-up 30 days postoperation. She did not receive any antibiotics or other prescription medications for this condition. Surgical pathology interpretation revealed ulcerated skin with abscess, umbilical remnant, granulation tissue, and foreign body suture material. At 1-month and 2-month wound check visits, the patient denied any pain, nausea, or vomiting. At next follow-up 6 months postoperation, the patient continued to do well without recurrence of her symptoms. A timeline of the patient’s history and care is presented in Fig. 2.
