AJR 2000; 174:1465-1466
© American Roentgen Ray Society
Color Doppler Sonography of Herniated Paraumbilical Collateral Vein Masquerading as an Acquired Umbilical Hernia
Refik M Killi,
Ömer Özütemiz and
Nevra Elmas
Ege University School of Medicine 35100 Bornova,
zmir, Turkey
Paraumbilical collateral veins, which accompany the ligamentum teres in the
falciform ligament of the liver, form anastomoses with the systemic venous
system by one or more of several routes and carry portal venous blood away
from the liver [1]. The
detection of recanalized paraumbilical collateral veins with hepatofugal flow
(velocity, >5 cm/sec) on Doppler sonography is a sign of portal
hypertension with 100% specificity
[2]. A sonographic study
reports a frequency of paraumbilical collateral veins in portal hypertension
ranging from 20% to 82% [2]. We
report an umbilical herniation of an enlarged paraumbilical collateral vein
viewed on color Doppler sonography.
A 72-year-old woman presented for workup of an umbilical mass and
splenomegaly. The patient had a 5-year history of liver cirrhosis, anemia,
hypertension, and diabetes mellitus. During her physical examination, we noted
an umbilical hernia (Fig. 1A) and a palpable spleen. The abdomen was obese and nontender without evidence of
ascites or caput medusae. Biochemical analysis revealed an elevated level of
hepatocellular enzymes, decreased level of serum albumin, and normal level of
bilirubin. Hematologic testing revealed features of anemia, and gray-scale
sonography revealed a cystic mass in the umbilicus extending cephalad in the
falciform ligament (Fig. 1B).
Color Doppler sonography revealed the presence of flow in the cystic mass, and
spectral Doppler sonography revealed a portal venous wave-form (Figs.
1C and
1D). CT confirmed herniation of
the paraumbilical collateral vein in the subcutaneous fat, through a defect
near the umbilicus. No additional evaluation or intervention is planned at
this time.
Two types of umbilical hernia exist: a congenital type and an acquired
type. The congenital type develops spontaneously during infancy and childhood,
caused by the incomplete closure of the umbilical ring. These hernias
disappear spontaneously and almost never incarcerate. Acquired umbilical
hernias are relatively rare, accounting for only 4% of all hernias, and
develop during adult life long after the normal closure of the umbilical ring
[2]. Acquired umbilical hernias
occur more commonly in women, usually after childbirth. Hernias typically
result from obesity, multiple pregnancies, weak abdominal walls,
intraabdominal masses, liver cirrhosis, and ascites. Common complications of
umbilical hernias include strangulation of the intestine or omentum in the
defect, incarceration causing intestinal obstruction, and rupture caused by
ascites [2]. Umbilical
herniation of a paraumbilical collateral vein is a very rare entity. To our
knowledge, only one report of umbilical herniation exists. Stallard et al.
[3] diagnosed an umbilical
herniation on CT and used color Doppler sonography to confirm the CT findings.
In our patient, umbilical herniation was detected during routine abdominal
color Doppler sonography, and CT was used as an additional diagnostic
technique.
Although rupture of an umbilical hernia in a patient with ascites is an
important, potentially fatal complication and surgical repair is often
recommended, surgeons must be cautious about repairing hernias in adult
patients with portal hypertension. In these patients, herniorrhaphy may damage
the paraumbilical collateral vein and cause fatal bleeding. Radiologists
should use Doppler sonography to assess the planned surgical field and to
reduce the danger of an already high-risk surgery
[2,3].
References
-
Lafortune M, Constantin A, Breton G, et al. The recanalized
umbilical vein in portal hypertension: a myth. AJR
1985;144:549
-553[Abstract/Free Full Text]
-
Khati NJ, Enquist EG, Javitt MC. Imaging of the umbilicus and
periumbilical region. RadioGraphics
1998;18:413
-431[Abstract]
-
Stallard DJ, Pozniak MA, Paulson BA. Ultrasound case of the day.
RadioGraphics
1993;13:480
-482[Medline]
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