Abstract – Introduction Urachal cyst is very rarely seen in adults. They are normally obliterated in early infancy. Urachal abnormalities are more common in children. – Case presentation -We describe a case of a 35 years South Indian male who presented with intermittent lower abdominal pain. He also had a history of discharge from umbilicus which subsided on treatment with antibiotics. No mass was palpable per abdomen. CT scan abdomen was done which showed a cystic lesion 1.3 x 1 cm about 4 cm inferior to the umbilicus which was suggestive of urachal cyst. Exploratory laparotomy was performed. Urachal cyst excised. The distal urachal ligament was obliterated and fibrous. No communication was found to the bladder. Histopathology confirmed it to be urachal cyst. Postoperative period was uneventful. Patient was relieved of abdominal pain on outpatient follow-up after 3 months – Conclusion -Urachal abnormalities are rare in adults. Clinical presentation was as chronic intermittent abdominal pain which was nonspecific. A high index of suspicion required to arrive at the diagnosis. The investigation modalities didn’t offer conclusive diagnosis.  Excision relieved the abdominal pain.

Introduction

Urachus or median umbilical ligament is obliterated allantois. It gets obliterated in fetal life. It extends from the bladder dome to the umbilicus. A partial or total defect in the process of obliteration of the allantois results in urachal abnormalities. They are usually detected in early childhood. They can very rarely present in adulthood. The clinical presentation is variable and makes the diagnosis difficult. Therefore we present a case which presented as intermittent abdominal pain and was difficult to diagnose even with modern diagnostic tools.

Case report

A 35 year old south Indian male presented to the surgical outpatient department with intermittent infraumbilical abdominal pain of 3 months duration. He gave a history of discharge from umbilicus for a few days which subsided on treatment with antibiotics by a general practitioner. The discharge was scanty , serous with turbidity. It was not having the odour of urine. No history of fever. On examination he was afebrile. Abdomen was soft, no mass palpable. There was tenderness in the hypogastric  region. The laboratory investigations were within normal limits. Ultrsonogram of the abdomen was reported as normal.

 

Fig 1 CT section at the level of the umbilicus

 

 

Fig 2 CT section showing the cyst inferior to the umbilicus with surrounding bowel filled with contrast

 

 

Fig 3 CT Section showing the cyst

The CT( Fig 1,2,3 ) scan was reported as cystic lesion 4cm inferior to the umbilicus on the inner surface of anterior abdominal wall which was a benign cyst or collection. A differential diagnosis of urachal cyst or a duplication cyst of sigmoid colon was provided by the radiologist. The size of the cyst being 1.3 x 1cm.Mild soft tissue thickening of umbilicus probably because of inflammation.  Exploratory laparotomy was done through a lower midline incision. A cyst of about 1.5cm was found about 3cm inferior to the umbilicus in the median umbilical ligament. The urachal remnant was traced from the umbilicus to the dome of the urinary bladder and was excised along with a cuff of bladder.(Fig 4,5)The bladder was sutured. The patient’s urinary bladder was catheterized preoperatively and was left in place. The post-operative course was uneventful. The patient was discharged from hospital. The urinary catheter was removed after 3 weeks. The abdominal pain with which the patient presented to us has subsided. No complications.

 

 

C

 

B

 

A

 

Fig 4 (A) Urachal cyst (B) Bladder end (C) Umbilical end

Fig 5a

 

Fig 5b

Fig 5c

The histopathology was consistent with urachal cyst. No malignancy. (Fig 5a,b and c)

Discussion

Urachus is fibrous remnant of cloaca which connects the dome of the bladder to the umbilicus in adults. The cloaca in fetal life is an extension of the urogenital sinus and allantois and is derived from the yolk sac. It obliterates to become median umbilical ligament after birth which is the urachus.

Abnormalities of the urachus can present as follows:-

1)      Patent urachus where there is a communication between the bladder and umbilicus.

2)      Umbilical sinus urachus communicates to the umbilicus but not to the bladder. It presents as discharge from the umbilicus.

3)      Vesico- urachaldiverticulam in which the urachus communicates with the bladder but not the umbilicus. There will be urinary complaints.

4)      Urachal cyst in which either side is obliterated. It can present as abdominal pain when infected. In adults it may open out to the umbilicus to become a sinus.

Urachal anomalies are more common in men. They are very rare in adults.The most common modes of presentation in adults are urachalcancer (51%) and urachal cyst (35%) which are usually infected.[1]Our case which presented with clinical features of hypogastric abdominal pain and tenderness were not specific for urachal cyst. Abdominal pain can be the only symptom and can present as acute abdomen mimicking acute appendicitis or Meckel’s diverticulitis.[2]It is also reported that it can present as colo-urachal-cutaneous fistula.[6]  Ultrasound scan is helpful but it was normal in our case. CT scan is more diagnostic but was not able to precisely say that it is urachal cyst in our case because large bowel was seen close to the cyst giving rise to the suspicion of duplication cyst of the sigmoid colon. It is found that urachal cyst are well displayed in sagittal ultrasonogram and CT scan confirms the diagnosis.[3]B – flow ultrasound is found to be helpful to diagnose allantoid cyst in the fetus.[4]CT cannot differentiate infected urachal cyst from carcinoma arising in urachal cyst. Those cases will require a CT guided aspiration cytology to arrive at the diagnosis.[3]Even though incidence of malignancy is common in urachalremnanats the overall incidence is only 0.2%.[5] Tuberculosis can occur in urachal cyst. They may present  asinfraumbilical mass and low grade fever.[7] Sometimes infected urachal cyst may require incision and drainage initially followed by excision. Even though open excision of the urachal cyst is the common treatment modality laparoscopic excision [8] and robotic surgery[9] has also ben done.

Conclusion

Urachal abnormalities are rare in adults. Clinical presentation was as chronic intermittent abdominal pain which was nonspecific. A high index of suspicion required to arrive at the diagnosis. The investigation modalities didn’t offer conclusive diagnosis.  Excision relieved the abdominal pain.

Acknowledgements

Dr. Khalilur Rahman M.S., Assistant professor in Department of General Surgery at Saveetha medical college worked up, treated and wrote the manuscript. Dr. Rajesh M.S., Associate professor In Department of General Surgery at Saveetha medical college was involved in the workup and treatment of the patient. Prof. Shruthi Kamal M.S., Professor of operative surgery in Department of General surgery at Saveetha medical college reviewed the manuscript. Dr. Dinesh Kumar M.S., Assistant professor in Department of Surgery at Saveetha medical college assisted in editing. There is no conflict of interest and no financial interests.

References

1)      Ashley RA, Inman BA, Routh JC, RohlingerAL,Husmann DA, Kramer SA. Urachalanomalies:a longitudinal study of urachal remnants inchildren and adults. J Urol. 2007; 178:1615–1618.

2)      Qureshi K, Maskell D, McMillan C, WijewardenaC. An infected urachal cyst presentingas an acute abdomen – A case report. Int JSurg Case Rep. 2013; 4: 633–635.

3)      Jeong-Sik Yu, MD, ,  Ki Whang Kim, MD, ,  Hwa-Jin Lee, MD, ,  Young-Jun Lee, MD, ,  Choon-Sik Yoon, MD, and ,  Myung-Joon Kim, MD.Urachal Remnant Diseases: Spectrum of CT and US Findings. RadioGraphics 2001 21:2 , 451-461

4)      Torbjørn Moe Eggebø,HegeUllandDirdal, Philip vonBrandis. Allantoid cyst in the umbilical cord diagnosed with B – flow ultrasound. BMJ Case Reports 2012; doi:10.1136/bcr.03.2012.6064

5)      Bruins HM, Visser O, Ploeg M, Hulsbergen-van deKaa CA, Kiemeney LA, Witjes JA. The clinical epidemiology of urachal carcinoma: results of a large, population based study. J Urol 2012;188(4):1102-7

6)      Anna L. Peters,Marjan J.P. Kruijer, Hans Wiese,c and Paul C.M. Verbeek. A colo-urachal-cutaneous fistula in an 88-year-old male.Int J Surg Case Rep. 2012; 3(2): 55–58

7)      Tarun Jindal, Mir Reza Kamal, Jayesh Kumar Jha. Tuberculosis of the urachal cyst.  Korean J Intern Med 2013;28:103-105

8)      Hee Jong Jeong, Dong Youp Han,Whi-An Kwon. Laparoscopic Management of Complicated Urachal Remnants.Chonnam Med J 2013;49:43-47

9)      DaeKeun Kim, Jae Won Lee, Sung Yul Park, Yong Tae Kim, Hae Young Park, Tchun Yong Lee. Initial Experience with Robotic-Assisted Laparoscopic Partial Cystectomy in Urachal Diseases. Korean J Urol 2010;51:318-322

 

 

 

Author Details

First Authors :

NameDr.Khalilur Rahman. A, M.S.,

Designation     Assistant Professor

Department     General Surgery

Address            Department of surgery, Saveetha medical college, Saveetha                      University, Saveetha Nagar, Thandalam, Chennai 602105, India

Email                dr.khalil09@gmail.com

Phone               +91 9677198691

Fax                    +91 44 66726632

 

Corresponding Author :

NameDr.Khalilur Rahman. A, M.S.,

DesignationAssistant Professor

DepartmentGeneral Surgery

AddressDepartment of surgery, Saveetha medical college, Saveetha                      University, Saveetha Nagar, Thandalam, Chennai 602105, India

Emaildr.khalil09@gmail.com

Phone           +91 9677198691

Fax+91 44 66726632

 

Coauthors

NameDr. Rajesh, M.S.,

Designation Associate Professor

Department General Surgery

Address          Department of surgery, Saveetha medical college, Saveetha                      University, Saveetha Nagar, Thandalam, Chennai 602105, India

Email              drrajesh80@yahoo.com

Phone            +91 9444331763

Fax                 +91 44 66726632

 

Name           Prof.Shruthi Kamal. V, M.S.,

Designation Professor

Department General Surgery

Address          Department of surgery, Saveetha medical college, Saveetha                      University, Saveetha Nagar, Thandalam, Chennai 602105, India

Email             shruthivenkat2002@yahoo.co.in

Phone           +91 9840037030

Fax                 +91 44 66726632

 

Name            Dr. Dinesh Kumar. M.S.,

Designation Assistant Professor

Department General Surgery

Address          Department of surgery, Saveetha medical college, Saveetha                      University, Saveetha Nagar, Thandalam, Chennai 602105, India

Email            drdineshkumar83@gmail.com

Phone           +91 9962550251

Fax                +91 44 66726632

 

 

 

 

 

 

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