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126 Omphalitis

Figure 20.3: Early necrotising fasciitis beginning at the umbilicus.

Figure 20.5: Intestinal evisceration from omphalitis.

Peritonitis
Peritonitis may occur with or without intraperitoneal abscess collection. In
the absence of an abscess, the infection could resolve with use of broad-
spectrum intravenous antibiotics alone, and surgery is usually not required.
If an intraperitoneal abscess is confirmed by ultrasound, or there is no
facility for ultrasonography, then laparotomy is required. Any abscess is
drained and the peritoneal cavity thoroughly cleaned.
Abscesses
Abscesses may develop at various sites, but are frequently intraab-
dominal. Intraperitoneal abscess is drained at laparotomy. Retroperitoneal
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abscess is best drained by an extraperitoneal approach, but if located ante-
Figure 20.4: Advanced necrotising fasciitis involving upper abdominal and lower riorly in the retroperitoneal, an intraperitoneal approach may be required.
chest wall. Hepatic abscess should be properly localised by ultrasonography or CT
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myonecrosis. The scrotum is the most commonly affected by NF, but the scan. The abscess is aspirated by a wide-bore needle under imaging guid-
abdominal wall may also be involved (Figure 20.4). If treated early, peri- ance, and the abscess cavity is irrigated with normal saline. This can be
umbilical cellulitis can be controlled by use of parenteral broad-spectrum repeated once more if it recollects. In difficult cases, or in recurrence after
antibiotics. The antibiotic regime should always include an antianaerobe needle aspiration, open drainage may be required. If the abscess is multiple,
(e.g., metronidazole). parenteral antibiotics alone may suffice, and aspiration/drainage reserved for
NF should be treated by prompt debridement, removing all dead persistent cases. Abscesses may be located in the anterior abdominal wall or
and dying tissues, followed by daily dressing of the wound. If the baby in other superficial locations. These would require drainage.
is too ill for a general anaesthetic, the debridement can be performed Late Complications
by the bedside (using parenteral paracetamol or rectal paracetamol for
analgesia). The resulting wound will later require secondary closure (or Late complications occur several weeks, months, or years after ompha-
skin grafting if the defect is large). However, scrotal wounds may heal litis in the neonatal period.
well without secondary closure or skin grafting. 13 Portal Vein Thrombosis
Evisceration Portal vein thrombosis (PVT) is a complication with serious conse-
Intestinal evisceration is another frequently reported serious complication quences. Although an early complication, the major consequences
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(Figure 20.5). The eviscerated intestine is usually loops of small intestine, produced are in the long term. In one report of 200 patients undergoing
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but large intestine may be involved. Rarely, presentation may be late, and portosystemic shunt for portal hypertension due to PVT, 15% of the
the eviscerated intestine may be gangrenous. PVT was suspected to be the result of neonatal omphalitis. The throm-
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The eviscerated intestine should be covered by clean moist gauze, bosis may produce a carvernoma, which can cause biliary obstruction.
and placed in an intestinal bag (a transparent plastic bag will do if there A portosystemic shunt may be required if portal hypertension
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is no intestinal bag available). Care should be taken to ensure that the develops. Biliary obstruction is treated on its merit.
intestine is not twisted. Umbilical Hernia
Under general anaesthetic, the eviscerated intestine is cleaned and Umbilical hernia is a common problem in children in Africa, and
returned to the peritoneal cavity and the umbilicus repaired. If the several are the result of weakening of the umbilical cicatrix from
umbilical defect is narrow, it may require extension in the transverse neonatal omphalitis. The management of these hernias is discussed
plane. In the presence of features of peritonitis or intestinal gangrene, in Chapter 57.
a formal laparotomy needs to be done to drain any abscesses and clean Peritoneal Adhesions
the peritoneal cavity. Gangrenous intestine needs to be resected and Peritoneal adhesions are the result of previous subclinical or treated
intestinal continuity restored. peritonitis from omphalitis. The adhesions may produce intestinal