Belly Buttons Not Just About Innies, Outies, Or Piercings


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A detailed look at the most human of our parts, the belly button. What can the umbilicus share with us about disease? You'll be surprised!

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Belly Buttons Not Just About Innies, Outies, Or Piercings

  1. 1. Not Innies, Outies, or Piercings: Visual Examination of the Belly as a Gateway to Intra-Abdominal Diagnosis Patricia L. Raymond MD FACP FACG
  2. 2. Terms for the Central Indentation <ul><li>Omphalos (Greek) </li></ul><ul><li>Umbilicus (Roman) </li></ul><ul><li>Navel (Center; ‘Nabe’ or hub of a wheel, German) </li></ul><ul><li>Belly Button (1877 American) </li></ul>
  3. 3. &quot;Neither procreative nor nutritive, perhaps it is the navel's lack of obvious purpose, combined with its audacious, almost arrogant, spot right there in the middle of things, that sucks its admirers in.&quot; Deirdre Day-MacLeod
  4. 4. The Navel in Theology
  5. 5. Omphalos at Delphi <ul><li>Greek mythology: Zeus, seeking to discover the precise centre of the earth, arranged for two eagles to fly at the same speed, one from the east and the other from the west. </li></ul><ul><li>They met at Delphi, and so it was there, in a temple to Apollo, that the Greeks set up an omphalos — that is, a holy navel-stone — guarded by two golden eagles. </li></ul><ul><li>Apollo, explained Plato, ‘has his shrine at the world's centre and navel, to guide mankind.’ </li></ul>
  6. 6. Hindu <ul><li>The lotus flower is said to be the center of the universe. There is a story that it arose from the navel of God Vishnu, and at the center of the flower sat Brahma . </li></ul>Brahma on lotus from Vishnu's navel
  7. 7. <ul><li>In Hindu thinking, the navel is the ‘motionless hub of the wheel’; it may alternatively be viewed as the tree under which the Buddha sat when he achieved illumination at Bodhgaya. </li></ul>
  8. 8. &quot;Thy navel is like a round goblet, which wanteth not liquor: thy belly is like an heap of wheat set about with lilies.&quot; Song of Solomon, King James Bible
  9. 9. Navel Food? The Birth of Venus Goddess of Love and Beauty - Sandro Botticelli
  10. 10. Gazing at your Navel: Omphaloscopy <ul><li>Omphalopsychic: a mystics who gazed at their own navel so as to induce a hypnotic reverie. The Greek Christian monks of Mount Athos used a specific method of navel contemplation called Hesychasm. </li></ul><ul><li>Omphalomancy: Predicted how many children a woman would give birth to, by counting the number of knots (bumps in the fleshy plaiting) in her umbilical cord when she was born. </li></ul>
  11. 11. Leonardo’s Vitruvian Man <ul><li>The navel is naturally placed in the centre of the human body, and, if in a man lying with his face upward, and his hands and feet extended, from his navel as the centre, a circle be described, it will touch his fingers and toes. </li></ul>
  12. 12. Navel Location <ul><li>Golden Section, AKA &quot;Divine Proportion&quot; by philosophers and artists. This is a geometric proportion in which a line is divided so that the ratio of the length of the longer line segment to the length of the entire line is equal to the ratio of the length of the shorter line segment to the length of the longer line segment. </li></ul><ul><li>This Golden Section ratio has a numerical value of approximately 1.618. In other words, an ideal navel height is about 62% of the body height and is said to exhibit special beauty as the legs and torso appear in sound proportion. </li></ul>
  13. 13. Navel Location for Medicos <ul><li>At the level of the L3-L4 vertabrae </li></ul><ul><li>Skin ennervation by the T10 dermatome </li></ul>
  14. 14. Digression: Fuzzy Navel or Harry Navel (1980s) <ul><li>Mixed drink made from peach schnapps and orange juice 1:1. </li></ul><ul><li>Adding 1 or 1 1/2 oz of vodka to the fuzzy navel you have what is called a hairy navel, the more &quot;hair&quot; referring to the increased strength of alcohol in the drink. </li></ul>
  15. 15. Outies, Anyone? <ul><li>10% of all belly buttons </li></ul><ul><li>Transient outies during some pregnancies, usually resolves spontaneously </li></ul><ul><li>Unclear etiology </li></ul><ul><li>Plastic surgery (umbilicoplasty) is available at cost of $500-$2000 </li></ul>
  16. 16. Outie is not Umbilical Hernia <ul><li>A belly button that protrudes with abdominal muscle contraction, such as when coughing, sitting up, or straining </li></ul><ul><li>Most close on their own by age 1; up to 10 percent may take longer to heal. To prevent complications, umbilical hernias that don't disappear by age 4 or those that appear during adulthood may need surgical repair. </li></ul>
  17. 18. Embryology of the Umbilicus
  18. 19. Umbilical Cord Anatomy <ul><li>By 5 th week of fetal development </li></ul><ul><li>Replaces yolk sac for nutrients </li></ul><ul><ul><li>One vein </li></ul></ul><ul><ul><li>Two arteries </li></ul></ul><ul><ul><li>Wharton’s Jelly </li></ul></ul>
  19. 20. Umbilical Cord Anatomy <ul><li>Fetal blood in umbilical arteries </li></ul><ul><ul><li>Deoxygenated </li></ul></ul><ul><ul><ul><li>Artery because blood moving away from fetus’ heart </li></ul></ul></ul><ul><ul><li>Passes very close to the mother's blood in the placenta </li></ul></ul><ul><ul><li>Oxygen and nutrients pass from mother's blood to the fetus' blood </li></ul></ul><ul><ul><li>Waste passes from fetal blood to mother </li></ul></ul>
  20. 22. Umbilical Cord Anatomy: Wharton’s Jelly <ul><li>Wharton's Jelly </li></ul><ul><ul><li>Temperature change, creates a natural clamp on the umbilical cord </li></ul></ul><ul><ul><li>Halts placental blood return to the neonate </li></ul></ul><ul><ul><ul><li>Cord ceases pulsation </li></ul></ul></ul><ul><ul><li>< 5 minutes post partum if allowed to proceed naturally. </li></ul></ul>
  21. 23. Umbilical cords & the barber pole <ul><li>Bright red veins </li></ul><ul><li>Blue artery </li></ul><ul><li>Spirals through white Wharton's Jelly </li></ul><ul><li>Symbolized by the barber's pole. </li></ul>
  22. 24. Lotus Birth <ul><li>Umbilical nonseverance </li></ul><ul><ul><li>Called &quot;lotus birth“ </li></ul></ul><ul><li>Entire intact umbilical cord is allowed to dry like a sinew </li></ul><ul><li>Separates naturally (3rd day postpartum) </li></ul><ul><li>Leaves a healed umbilicus </li></ul>
  23. 25. Cord Blood Banking <ul><li>Source of primitive, undifferentiated stem cells </li></ul><ul><li>Some parents chose to have this blood diverted from the baby's umbilical blood transfer </li></ul><ul><ul><li>Early cord clamping and cutting </li></ul></ul><ul><ul><li>Frozen for long-term storage at a cord blood bank </li></ul></ul>
  24. 26. Cord Blood Banking Controversy <ul><li>Critics: Cord blood withdrawal at the critical time of birth increases the likelihood of childhood disease </li></ul><ul><li>High volume of blood taken </li></ul><ul><ul><li>Ave 108ml </li></ul></ul><ul><ul><li>Neonate's total typically 300ml </li></ul></ul><ul><li>Royal College of Obstetricians and Gynaecologists 2006 </li></ul><ul><ul><li>“ insufficient evidence to recommend directed commercial cord blood collection and stem-cell storage in low-risk families.&quot; </li></ul></ul>
  25. 27. Social Implications of the Navel <ul><li>I Dream of Jeannie </li></ul><ul><li>Single female could live with single male, so long as it was clear that she slept in a bottle </li></ul><ul><li>Could not show belly button on TV, although was seen in most publicity stills </li></ul>
  26. 29. Piercing & Tattoos
  27. 30. Foreign Body Reaction
  28. 31. Endocarditis <ul><li>16 y/o girl with septicemia, septic arthritis of the wrist, and tricuspid endocarditis 3 months after a navel piercing </li></ul><ul><li>Blood and joint culture positive for Staphylococcus aureus. </li></ul><ul><li>Prolonged intravenous antibiotics with progressive regression of endocarditis, without surgical intervention. </li></ul><ul><li>Piercings must be done antiseptically </li></ul><ul><li>Advise against in patients with congenital heart disease. </li></ul>Archives des maladies du coeur et des vaisseaux (Arch Mal Coeur Vaiss), Reference: 2006-Jun; vol 99 (issue 6) : pp 629-31
  29. 32. Temporary Removal of Navel Piercing Jewelry for Surgery and Imaging Studies <ul><ul><li>1) Disinfect the piercing and umbilical area with 70% isopropyl alcohol </li></ul></ul><ul><ul><li>2) Open the piercing jewelry by removing the bead from the bar </li></ul></ul><ul><ul><li>3) Place the tip of a tight-fitting intravenous catheter (14 or 16 gauge, without the needle) over the threaded tip of the bar </li></ul></ul>Oliver J. Muensterer, MD , PEDIATRICS Vol. 114 No. 3 September 2004, pp. e384-e386
  30. 33. Temporary Removal of Navel Piercing Jewelry for Surgery and Imaging Studies <ul><li>4) Advance the intravenous catheter caudally, pushing the piercing out of the skin tract </li></ul><ul><li>5) Remove the jewelry and leave the intravenous catheter in the subcutaneous skin tract as a spacer. </li></ul><ul><ul><li>6) After the intervention, reinsert the piercing jewelry by following the described steps in reverse order. </li></ul></ul>
  31. 34. Navel in Marketing Thailand's Sealect Tuna Diet Commercial Patricia Raymond
  32. 35. Social Stigma: No Belly Button
  33. 37. How to Pull Money Out of Your Navel <ul><li>November 1974, Poughkeepsie NY </li></ul><ul><li>Virginia O’Hare (42) vs plastic surgeon Howard Bellin </li></ul><ul><li>Belly button 2” off center post abdominoplasty </li></ul><ul><ul><li>Returned to it’s proper place by another surgeon </li></ul></ul><ul><li>State Supreme Court jury award of $854,217 , settled for $200,000 </li></ul>
  34. 38. Navel Medicine <ul><li>Sister Mary Joseph Nodule </li></ul><ul><li>Cullen’s Sign </li></ul><ul><li>Grey-Turners Sign </li></ul><ul><li>Caput Medusae </li></ul><ul><li>Umbilical Fistula </li></ul><ul><li>Dance’s Sign </li></ul><ul><li>Endometrioma of umbilicus </li></ul><ul><li>Tanyol’s Sign </li></ul><ul><li>Striae </li></ul>Navel Surgeon
  35. 39. Sister Mary Joseph Nodule <ul><li>Sister Mary Joseph, surgical assistant to W.J. Mayo MD in Rochester </li></ul><ul><li>Noted this finding as she prepped patients for exploratory laparotomy, later to be found to have advanced stage malignancy </li></ul>
  36. 40. Sister Mary Joseph Nodule <ul><li>NO nodule </li></ul><ul><li>Thickening or inflammation of periumbilical subQ tissue, resembling cellulitis </li></ul><ul><li>Red, white, bluish violet, brownish red, depending on underlying malignancy </li></ul><ul><li>Diagnosis by biopsy </li></ul>
  37. 41. Sister Mary Joseph Nodule Associated tumors <ul><li>Stomach </li></ul><ul><li>Colon/rectum </li></ul><ul><li>Ovary </li></ul><ul><li>Uterus </li></ul><ul><li>Breast </li></ul><ul><li>Kidney </li></ul><ul><li>Fallopian tube </li></ul><ul><li>Pancreas </li></ul><ul><li>Prostate </li></ul><ul><li>Also gallbladder, lung, small intestine, cervix </li></ul><ul><li>In rare cases, may represent a solitary metastatic site; may still be curable </li></ul>
  38. 42. Mayo himself, on the Sister Mary Joseph Nodule <ul><li>“Before such a patient is submitted to x-ray examination and other tests… </li></ul><ul><li>in order to protect the patients’ </li></ul><ul><li>time, strength, and pocketbook, </li></ul><ul><li>whether there is visible or palpable evidence </li></ul><ul><li>of metastatic extension </li></ul><ul><li>which would at once make </li></ul><ul><li>the diagnosis and prognosis clear.” </li></ul>
  39. 43. Modern SMJ Nodule <ul><li>Umbilical piercing leading to presentation of ovarian cancer .  P. Sanghera , A . El-Modir, </li></ul><ul><li>The Lancet Oncology , Volume 6 , Issue 9 , Pages 730 - 730 </li></ul><ul><ul><li>43-year-old woman presented to her MD 2 weeks after umbilical piercing. </li></ul></ul><ul><ul><li>Abdominal pain and discharge from the pierced umbilicus. </li></ul></ul><ul><ul><li>No other symptoms and no past medical history. </li></ul></ul><ul><ul><li>Tender, discrete discharging mass in the umbilical region but no other findings. </li></ul></ul><ul><ul><li>Thought to have an abscess after the piercing, referred to the local hospital for excision and drainage </li></ul></ul>
  40. 44. Cullen’s & Grey-Turners Signs <ul><li>Cullen’s Sign </li></ul><ul><ul><li>Bluish or yellowish bruising of umblicus and surrounding skin </li></ul></ul><ul><ul><ul><li>Depends on stage of hemoglobin breakdown </li></ul></ul></ul><ul><li>Described in 1909 </li></ul><ul><ul><li>Ruptured ectopic pregnancy </li></ul></ul><ul><li>Also with hepatoma, liver biopsy, ruptured AAA, acute pancreatitis </li></ul>
  41. 45. Cullen’s & Grey-Turners Signs <ul><li>Grey-Turners Sign </li></ul><ul><ul><li>Discoloration of flanks with acute hemorrhagic pancreatitis </li></ul></ul>
  42. 46. Caput Medusae <ul><li>Umbilical Varices </li></ul><ul><li>Due to portal hypertension </li></ul><ul><ul><li>Not due to recannulation of umbilical vein as route for portosystemic circulation </li></ul></ul>
  43. 47. Umbilical Fistula <ul><li>Crohn’s disease </li></ul><ul><li>Patent vitellointestinal duct: fecal discharge </li></ul><ul><li>Patent urachus: urine discharge </li></ul><ul><li>Also: </li></ul><ul><ul><li>Tuberculosis </li></ul></ul><ul><ul><li>Cholocystoumbilical fistula “gravel” </li></ul></ul><ul><ul><li>Amniotic fluid </li></ul></ul><ul><ul><li>Roundwoms </li></ul></ul>
  44. 48. Dance’s Sign <ul><li>Right lower quadrant retraction, which can be an indication of intussusception </li></ul><ul><li>Ileocecal intussuseption is usually seen in children </li></ul>
  45. 49. Endometrioma of umbilicus <ul><li>Rare </li></ul><ul><li>Cyclic hemorrhage seen with menses </li></ul>
  46. 50. Tanyol’s Sign <ul><li>Umbilicus normally at L3-L4 </li></ul><ul><li>Pregnancy displaces upward </li></ul><ul><li>Ascites displaces downward </li></ul><ul><ul><li>Do not use this sign as sole differentiation of pregnancy vs ascites! </li></ul></ul>
  47. 51. Striae <ul><li>Distensae, gravidarum, or atrophicae </li></ul><ul><li>Depressed, elevated, or edematous </li></ul><ul><li>Glucocorticoid excess become broader and deep purplish red with time </li></ul><ul><ul><li>Others fade and become atrophic </li></ul></ul>
  48. 52. Belly Button Fluff: Graham Barker <ul><li>Collecting and storing his own BBF </li></ul><ul><li>Started 17 January 1984 </li></ul><ul><li>Three bottles of BBF </li></ul><ul><ul><li>3.03 mg per day </li></ul></ul><ul><ul><li>1.1 grams per year </li></ul></ul><ul><li>November 2000, the Guinness World Records : Largest collection of BBF in the world </li></ul>
  49. 53. Belly Button Lint/Fluff: What is it? Where does it come from? <ul><li>EM studies </li></ul><ul><ul><li>Dead skin </li></ul></ul><ul><ul><li>Clothing fibers </li></ul></ul>
  50. 54. Risk factors for BBL : Male, older, hairy, innie <ul><li>More specifically... </li></ul><ul><li>More BBL as you age </li></ul><ul><li>More men have BBL than women </li></ul><ul><li>No relationship between BBL and BMI. </li></ul><ul><li>Lint color reflects your skin tone - lint is lighter for light skinned people. </li></ul><ul><li>BBL appears to be related to hairiness. </li></ul><ul><ul><li>Too much belly hair, or too little belly hair somehow inhibits the movement of BBL into the belly button. </li></ul></ul><ul><ul><li>‘ Snail Trail’ enhances BBL level </li></ul></ul><ul><li>Anecdotal evidence: navel rings dramatically reduce BBL </li></ul>
  51. 55. Belly buttons and life <ul><li>Gerhard Reibmann </li></ul><ul><ul><li>Berlin psychologist </li></ul></ul><ul><li>Dx life expectancy, general health and psychological state by inspecting the umbilicus </li></ul><ul><li>His book: Centred: Understanding Yourself Through Your Navel . </li></ul>
  52. 56. Reibmann’s six forms of umbilicus <ul><li>Horizontal navel </li></ul><ul><ul><li>Highly emotional, life expectancy 68 years </li></ul></ul><ul><li>Vertical navel </li></ul><ul><ul><li>Generous, self-confident and emotionally stable, life expectancy 75 years </li></ul></ul><ul><li>Outie </li></ul><ul><ul><li>Optimistic and enthusiastic, life expectancy 72 years </li></ul></ul>
  53. 57. Reibmann’s six forms of umbilicus <ul><li>Concave, bowl-shaped navel </li></ul><ul><ul><li>Gentle, loving, cautious, delicate, sensitive and rather prone to worrying. </li></ul></ul><ul><ul><li>Shortest life expectancy; only 65 years </li></ul></ul><ul><li>Off-center </li></ul><ul><ul><li>Fun-loving and to have wide emotional swings. Life expectancy 70 years </li></ul></ul><ul><li>Evenly shaped and circular navel </li></ul><ul><ul><li>Modest and even tempered and has a quiet, retiring personality; life expectancy 81 years. </li></ul></ul>
  54. 58. “ Thought depends absolutely on the stomach, but in spite of that, those who have the best stomachs are not the best thinkers.&quot; Voltaire Letter to D’Alembert
  55. 59. Questions???