Patent vitellointestinal duct with prolapse of inverted loop of small intestine: a case report

A wide variety of anomalies may occur as a result of the vitellointestinal duct (VID) failing to obliterate completely. Most reports on symptomatic VID focus on Meckel's diverticulum, while other anomalies are given little attention. We report a case of a baby of five months who had an intestinal loop inverted through a patent VID. The inverted loop was reduced and ileostomy was done which was closed after 6 weeks. Background Anatomy The midgut enlarges rapidly during the first 5 weeks of gestation and becomes too large for the abdominal cavity; subsequently, it is herniated into the umbilical cord. The apex of the herniated midgut is continuous with the vitellointestinal duct and the yolk sac. The axis of the herniated midgut is formed by the superior mesenteric artery. At approximately the 10th week of gestation, the midgut begins its return into the abdominal cavity. This return occurs by a highly complex developmental process, and as a result, numerous anomalies of the bowel may ensue. These include bowel atresias and stenoses, abnormalities of the vitellointestinal duct, failure of ceacal descent, malrotation, malfixation, reversed bowel rotation and exomphalos. Case presentation 5 months old male child came with unusual red colored 'Y' shaped loop emerging from the anterior abdominal wall with absent umbilicus. The parents reported that the baby had a small opening in the umbilicus since birth which discharged a sticky greenish material in very small quantity. The child was suffering from cough since 4 days leading to protrusion of the red colored mass from the umbilicus which was small initially but grew over these 4 days till it became carrot sized. Then a branch developed giving it a 'Y' shape. On careful examination we found that the loop was the 'y' shaped fork (See Figure 1). One of the tips of the mass was discharging sticky greenish fluids suggestive of intestinal juices. The stem of the 'Y' shaped loop was protruding from umbilicus and fixed to the anterior abdominal wall. The loop was irreducible and bled on touch suggestive of mucosal surface. Ultrasound examination of the abdomen was found absolutely normal. Laparotomy was performed under general anaethesia. The baby was put through a laparotomy under Published: 14 July 2007 Journal of Medical Case Reports 2007, 1:49 doi:10.1186/1752-1947-1-49 Received: 19 February 2007 Accepted: 14 July 2007 This article is available from: http://www.jmedicalcasereports.com/content/1/1/49 © 2007 Mohite et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Page 1 of 4 (page number not for citation purposes) Journal of Medical Case Reports 2007, 1:49 http://www.jmedicalcasereports.com/content/1/1/49 general anesthesia. A small transverse incision of 4 centimeters was made just below the umbilicus. The outer surface of the emerging loop was firmly adherent to all the layers of the anterior abdominal wall. It was dissected from the abdominal wall layers with the fine scissors. Two different non-adherent loops of small intestine were found entering the emerging carrot like mass (See Figure 3). The distal loop entering into the umbilicus was slowly pulled inside the peritoneal cavity with extreme delicacy to find that the outer loop was diminishing in size and finally disappeared (See Figure 4). The procedure was applied for the proximal loop also (See Figure 5). After complete reduction (See Figure 6) a defect of 2 × 2 centimeters was found in the small intestine (See Figure 2) at the point of adherence with the abdominal wall suggesting its patency with external environment through the umbilicus. We diagnosed the case as patent vitellointestinal duct. Primary resection anastomosis was not possible because of the gross edema over the loop of intestine. The loop with the defect was brought out through another incision in the abdomen at right iliac fossa as loop ileostomy. The defect of Patent VID over the abdominal wall was primarily closed the umbilicus was reconstructed. Ileostomy was closed after 6 weeks. Patient condition was followed up for about 6 months with no reports of any complications. Discussion Failure of obliteration of the embryonic vitellointestinal duct leads to various congenital anomalies like – Meckel's diverticulum, vitelline cord, enteric cyst, umbilical sinus, enteric fistula or hemorrhagic umbilical mass [1]. Patient may present the anomaly itself or due to complications secondary to the anomalies like intestinal obstruction due to volvulus, intussusception or adhesions [2,3]. Totally patent VID is a very rare anomaly and very few cases were reported in the literature. We found a single case report of ileal prolapse through the patent VID. It was reported in 1985 by Dr. Gvalani AK [4]. Patent vitellointestinal duct may present itself as continuous or intermittent discharge cross-sectional diagrammatic representation of the condition on presentation Figure 3 cross-sectional diagrammatic representation of the condition on presentation. picture on presentation Fig 1 picture on presentation. picture on reduction of prolapse Fig 2 picture on reduction of prolapse. Page 2 of 4 (page number not for citation purposes) Journal of Medical Case Reports 2007, 1:49 http://www.jmedicalcasereports.com/content/1/1/49 Publish with BioMed Central  and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp BioMedcentral through the umbilicus. The defect which is wide enough or the predisposing conditions which increase intra abdominal pressure leads to partial or total prolapse of the intestine through the patent duct. The condition, if not managed promptly by surgical intervention, may lead to subacute or acute intestinal obstruction, strangulation and gangrene of the prolapsed intestinal loop. Primary closure of the VID following reduction of the prolapse may be possible if the patient arrives early without any gross edema over the intestinal loops. If the defect is large one can go for resection of the loop of intestine near the patent duct followed by primary anastomosis. If the patient arrives late with gross edema or the viability of the intestinal loops is in question then exteriorization of the suspected loop or loop ileostomy is advised. Conclusion Patent VID with prolapsed ileal loop is a rare condition needs prompt diagnosis, surgical reduction and repair of the defect. Abbreviations VID: vitellointestinal duct Competing interests The author(s) declare that they have no competing interests. Authors' contributions All the authors read and approved the manuscript. PNM: Did the surgery, prepared the manuscript AMB: Guided during surgery, helped in searching references. VPH: Gave final touch to the manuscript JHM: Assisted the surgery, assisted drafting the manuscript on complete reduction-with patent VID Figure 6 on complete reduction-with patent VID. Following color coding is used for all the figures 3 to 6. Black shaded area: abdominal wall. Blue: mesenteric border. Green: antimesenteric border on reduction of the distal loop Figure 4 on reduction of the distal loop. on reduction of proximal loop Figure 5 on reduction of proximal loop. Page 3 of 4 (page number not for citation purposes) Journal of Medical Case Reports 2007, 1:49 http://www.jmedicalcasereports.com/content/1/1/49 Publish with BioMed Central  and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp BioMedcentral Acknowledgements Mrs. Anupama Nair, Vadodara, India helped in writing the manuscript. Permission for the publishing of the case report is taken from the patients parents. References 1. Chang LS: Vitelline duct remnant appearing as a hemorrhagic umbilical mass. JAMA 1982, 247:2812-3. 2. Ladd WF, Gross RE: Abdominal surgery of infancy and childhood Philadelphia, W B Saunders and Co; 1941:72. 3. James Lister, Irene Irving: 'Neonatal Surgery' Umbilical anomalies Volume Chapter 27. Third edition. Butterworth & Co; 1990:397. 4. Gvalani AK, Acharya GV, Rao RV, Dawookkar VV: Ileal prolapse through a patent vitellointestinal. Indian Practitioner 1985, 38(7):629-32. Page 4 of 4 (page number not for citation purposes)


Anatomy
The midgut enlarges rapidly during the first 5 weeks of gestation and becomes too large for the abdominal cavity; subsequently, it is herniated into the umbilical cord. The apex of the herniated midgut is continuous with the vitellointestinal duct and the yolk sac. The axis of the herniated midgut is formed by the superior mesenteric artery. At approximately the 10th week of gestation, the midgut begins its return into the abdominal cavity. This return occurs by a highly complex developmental process, and as a result, numerous anomalies of the bowel may ensue. These include bowel atresias and stenoses, abnormalities of the vitellointestinal duct, failure of ceacal descent, malrotation, malfixation, reversed bowel rotation and exomphalos.
Case presentation 5 months old male child came with unusual red colored 'Y' shaped loop emerging from the anterior abdominal wall with absent umbilicus. The parents reported that the baby had a small opening in the umbilicus since birth which discharged a sticky greenish material in very small quantity. The child was suffering from cough since 4 days leading to protrusion of the red colored mass from the umbilicus which was small initially but grew over these 4 days till it became carrot sized. Then a branch developed giving it a 'Y' shape.
On careful examination we found that the loop was the 'y' shaped fork (See Figure 1). One of the tips of the mass was discharging sticky greenish fluids suggestive of intestinal juices. The stem of the 'Y' shaped loop was protruding from umbilicus and fixed to the anterior abdominal wall. The loop was irreducible and bled on touch suggestive of mucosal surface.
Ultrasound examination of the abdomen was found absolutely normal. Laparotomy was performed under general anaethesia. The baby was put through a laparotomy under general anesthesia. A small transverse incision of 4 centimeters was made just below the umbilicus. The outer surface of the emerging loop was firmly adherent to all the layers of the anterior abdominal wall. It was dissected from the abdominal wall layers with the fine scissors. Two different non-adherent loops of small intestine were found entering the emerging carrot like mass (See Figure  3). The distal loop entering into the umbilicus was slowly pulled inside the peritoneal cavity with extreme delicacy to find that the outer loop was diminishing in size and finally disappeared (See Figure 4). The procedure was applied for the proximal loop also (See Figure 5). After complete reduction (See Figure 6) a defect of 2 × 2 centimeters was found in the small intestine (See Figure 2) at the point of adherence with the abdominal wall suggesting its patency with external environment through the umbilicus. We diagnosed the case as patent vitellointestinal duct. Primary resection anastomosis was not possible because of the gross edema over the loop of intestine. The loop with the defect was brought out through another incision in the abdomen at right iliac fossa as loop ileostomy. The defect of Patent VID over the abdominal wall was primarily closed the umbilicus was reconstructed. Ileostomy was closed after 6 weeks. Patient condition was followed up for about 6 months with no reports of any complications.

Discussion
Failure of obliteration of the embryonic vitellointestinal duct leads to various congenital anomalies like -Meckel's diverticulum, vitelline cord, enteric cyst, umbilical sinus, enteric fistula or hemorrhagic umbilical mass [1]. Patient may present the anomaly itself or due to complications secondary to the anomalies like intestinal obstruction due to volvulus, intussusception or adhesions [2,3]. Totally patent VID is a very rare anomaly and very few cases were reported in the literature. We found a single case report of ileal prolapse through the patent VID. It was reported in 1985 by Dr. Gvalani AK [4]. Patent vitellointestinal duct may present itself as continuous or intermittent discharge cross-sectional diagrammatic representation of the condition on presentation through the umbilicus. The defect which is wide enough or the predisposing conditions which increase intra abdominal pressure leads to partial or total prolapse of the intestine through the patent duct. The condition, if not managed promptly by surgical intervention, may lead to subacute or acute intestinal obstruction, strangulation and gangrene of the prolapsed intestinal loop. Primary closure of the VID following reduction of the prolapse may be possible if the patient arrives early without any gross edema over the intestinal loops. If the defect is large one can go for resection of the loop of intestine near the patent duct followed by primary anastomosis. If the patient arrives late with gross edema or the viability of the intestinal loops is in question then exteriorization of the suspected loop or loop ileostomy is advised.

Conclusion
Patent VID with prolapsed ileal loop is a rare condition needs prompt diagnosis, surgical reduction and repair of the defect.

Competing interests
The author(s) declare that they have no competing interests.

Authors' contributions
All the authors read and approved the manuscript.
PNM: Did the surgery, prepared the manuscript AMB: Guided during surgery, helped in searching references.
VPH: Gave final touch to the manuscript JHM: Assisted the surgery, assisted drafting the manuscript on complete reduction-with patent VID Figure 6 on complete reduction-with patent VID. Following color coding is used for all the figures 3 to 6. Black shaded area: abdominal wall. Blue: mesenteric border. Green: antimesenteric border on reduction of the distal loop