An umbilical granuloma results from excessive growth of normal granulation tissue on the umbilical stump. Prevention of umbilical granuloma formation is usually accomplished by keeping the umbilical cord clean and dry and by applying a topical antimicrobial agent daily (e.g., isopropyl alcohol or bacitracin) (1). Removal of an umbilical granuloma is a simple procedure, usually performed in the office setting or a low-acuity area of the emergency department.

The umbilical cord normally comprises the umbilical vein and two umbilical arteries embedded in a gelatinous substance called Wharton’s jelly. Umbilical cord separation usually occurs 1 to 2 weeks after birth; delayed cord separation beyond 7 to 8 weeks of age may be associated with defects in cellular immunity or chemotaxis (2,3,4). The remaining umbilical stump is covered by a thin layer of skin. This epithelialization typically occurs within 12 to 15 days following separation. Over time, the umbilical arteries become the lateral umbilical ligaments, and the umbilical vein becomes the ligamentum teres.

Although the blood vessels in the stump are functionally closed following cord separation, they remain anatomically patent. While patent, the blood vessels are potential portals of entry for invasive pathogens such as Staphylococcus aureus, group B streptococci, and Clostridium tetani.

An umbilical granuloma is formed when epithelialization of the umbilicus is incomplete and normal granulation tissue grows excessively. The resulting granuloma is soft and vascular, with pink or cherry-red coloration. It typically measures 3 to 10 mm in diameter and may be associated with small amounts of bleeding or drainage. It is unclear if low-grade infection or bacterial colonization plays a role in umbilical granuloma formation (4).

Small umbilical granulomas often regress with continued application of isopropyl alcohol (5). However, large or pedunculated umbilical granulomas frequently bleed and may lead to umbilical disfigurement. In general, large or bleeding granulomas deserve removal.

Several umbilical abnormalities must be differentiated from an umbilical granuloma before any attempt is made at removal (Table 88.1 and Fig. 88.1). Omphalitis, characterized by periumbilical erythema and cord drainage, is caused by bacterial infection of the umbilical stump. Pathogens include group A streptococci, group B streptococci, and S. aureus. This condition represents a true cellulitis of the abdominal wall that may extend internally via the still patent umbilical vessels to cause liver abscess, portal vein thrombosis, and umbilical arteritis. Abscess formation within the cord may cause a red umbilical mass that might be mistaken for an umbilical granuloma. However, the presence of fever and periumbilical erythema should lead to the correct diagnosis.

An omphalomesenteric or vitelline duct results from the persistence of the embryologic connection between the umbilicus and the ileum. It presents as a pale pink orifice that releases flatus or feculent discharge and is often adjacent to an umbilical polyp. Umbilical polyps are remnants of the omphalomesenteric duct. An umbilical polyp appears bright red and nodular. It may be associated with mucoid discharge and is comprised of intestinal mucosa.