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Basics ⬇

Outline

BASICS

Overview!!navigator!!

  • Omphalophlebitis, or “navel ill,” is an infection of 1 or more of the umbilical structures. Omphalophlebitis technically refers to infection of the umbilical vein, and omphalitis refers to infection of any of the umbilical structures. The structures that comprise the umbilicus—the umbilical vein, umbilical arteries, and urachus—can become infected alone or in combination, with the urachus most commonly affected. Infection of the umbilicus can occur secondary to ascending bacterial invasion from open umbilical structures or from hematogenous seeding in a septicemic foal
  • The normal umbilicus should not be patent beyond 24 h and should become dry and involute by 3–7 days. The umbilicus should be essentially nonexistent by 3–4 weeks of age. The bacteria most commonly associated with septic omphalophlebitis are similar to those associated with neonatal septicemia, such as β-hemolytic streptococci, Escherichia coli, and Actinobacillus sp.

Signalment!!navigator!!

  • Most commonly seen in neonatal foals, usually several days of age, although umbilical abscesses have been reported in older foals and horses (reported up to 16 months of age)
  • No breed or sex predisposition

Signs!!navigator!!

  • External abnormalities are seen in approximately 50% of cases
  • Swollen, warm, and painful umbilicus
  • Ventral edema may be present in more chronic cases
  • Purulent discharge may be seen, and urine may leak due to presence of a patent urachus
  • Deeper palpation may reveal thickened umbilical arteries and/or vein
  • Fever, lethargy, and poor nursing are often recognized first. Secondary complications such as septicemia, septic arthritis, septic physitis, and pneumonia may be the most obvious clinical signs—the umbilicus should be carefully examined in these cases

Causes and Risk Factors!!navigator!!

  • FTPI
  • Poor hygiene in the foaling environment
  • Septicemia
  • Contamination of the umbilical remnant or improper care of the umbilicus

Diagnosis ⬆ ⬇

Outline

DIAGNOSIS

Differential Diagnosis!!navigator!!

  • Patent urachus—this may occur secondary to omphalophlebitis especially if it is an acquired patent urachus; can occur as a primary congenital condition in the absence of omphalophlebitis—history and US examination can help to differentiate
  • Umbilical hernia—an uncomplicated hernia should not have palpable heat, drainage, or enlargement of external or internal umbilical remnant structures. Foals with uncomplicated hernias generally do not have signs of systemic illness such as fever or lethargy

CBC/Biochemistry/Urinalysis!!navigator!!

  • An increase in WBC count and fibrinogen is commonly seen
  • If the urachus is involved, urinalysis may reveal WBCs and bacteria

Other Laboratory Tests!!navigator!!

  • IgG should be evaluated, as FTPI is a common risk factor for omphalophlebitis
  • SAA may increase with omphalophlebitis

Imaging!!navigator!!

US

  • US of umbilical remnants using a 7.5 MHz probe—the urachus, umbilical arteries, umbilical vein, and bladder should be evaluated. The examination can be performed with the foal standing or restrained in lateral recumbency. Saturate the hair with alcohol and use US coupling gel. Clipping is not necessary but will improve image quality
  • Normal umbilical vein should measure <1 cm in diameter, and normal umbilical arteries should measure <1.3 cm. The combined umbilical arteries and urachus should measure <2.5 cm at the apex of the bladder
  • Affected structures will generally be enlarged with a fluid-filled core, and often with gas shadowing

Abdominal Radiography

Positive-contrast radiographs of the urinary tract (retrograde via the urethra) can help to identify any urachal tears that may be present secondary to umbilical sepsis.

Other Diagnostic Procedures!!navigator!!

  • Blood cultures in neonatal foals to confirm septicemia and guide antimicrobial therapy
  • Culture of umbilical stump to guide antimicrobial therapy
  • Additional imaging may be required to assess for pneumonia, enteritis, and septic physitis

Treatment ⬆ ⬇

TREATMENT

  • Surgical resection of umbilical remnants—indicated if there is not adequate response to medical treatment, the umbilicus is severely enlarged and unlikely to respond quickly to medical therapy, or there is leakage of urine from the urachus. Surgical marsupialization of the umbilical vein remnant has been reported in cases where complete resection of the infected remnant was not possible
  • Nursing care—the foal should be supported systemically if there is concurrent septicemia, inappetence, or dehydration. Septicemic foals should be hospitalized and may require emergency medical care

Medications ⬆ ⬇

Outline

MEDICATIONS

Drug(s) of Choice!!navigator!!

  • Systemic antimicrobials—broad-spectrum antibiotics should be continued as required for resolution of the infection, often for at least 2 weeks. The choice of antimicrobials will be guided by culture results, but a common initial choice is a penicillin (22 000 IU/kg IV QID) and an aminoglycoside (amikacin 25 mg/kg IV every 24 h). If long-term antimicrobials are needed, the choice of an oral antimicrobial may be guided by culture results, and the foal should be monitored closely to ensure that there is not a recurrence of infection
  • NSAIDs—as needed for treatment of umbilical inflammation, fever, and discomfort or postoperatively to reduce the risk of adhesion formation and to reduce incisional discomfort. Flunixin meglumine (0.25–1.1 mg/kg IV BID) or ketoprofen (0.5–1.1 mg/kg IV BID)

Contraindications/Possible Interactions!!navigator!!

  • Aminoglycosides should be used with caution in dehydrated foals or foals with renal compromise. Alternatively, a cephalosporin such as ceftiofur (10 mg/kg IV QID) may be used
  • Gastroduodenal ulcer prophylaxis may be needed when NSAIDs are used. NSAIDs should be used with caution in neonates and dehydrated foals of any age

Follow-up ⬆ ⬇

Outline

FOLLOW-UP

Patient Monitoring!!navigator!!

  • Foals should be monitored closely with palpation and serial US examinations for response to therapy
  • Twice-daily physical examinations should be performed to monitor for septic arthritis, septic physitis, and other possible complications
  • Follow-up blood work should reveal a decrease in fibrinogen/SAA and normalization of the leukogram

Prevention/Avoidance!!navigator!!

  • Provide good hygiene in the foaling environment
  • Ensure adequate transfer of passive immunity—check IgG and administer plasma if IgG < 800 mg/dL
  • Dipping of the umbilical stump with dilute chlorhexidine (0.5%) or dilute povidone–iodine (1.0%) may help to prevent ascending infection

Possible Complications!!navigator!!

  • Primary or secondary septicemia can occur in association with omphalophlebitis, with septic arthritis being the most common complication
  • Septic physitis, osteomyelitis, and pneumonia may also occur in combination with omphalophlebitis
  • Acquired patent urachus is a possible sequela
  • Infection of the urachus can lead to necrosis and possible uroabdomen and/or subcutaneous leakage of urine
  • Extension of venous abscess to the liver

Expected Course and Prognosis!!navigator!!

  • Foals with small, focal umbilical remnant infections usually respond to medical therapy. In foals with more extensive infection of the umbilical structures, surgical resection of the umbilical remnants appears to improve survival due to the reduced incidence of secondary infections
  • The presence of infected joints worsens the prognosis

Miscellaneous ⬆ ⬇

Outline

MISCELLANEOUS

Associated Conditions!!navigator!!

  • Patent urachus
  • Septicemia
  • Septic arthritis

Age-Related Factors!!navigator!!

Umbilical remnant infection is most commonly a condition of neonatal foals, and this population should also be evaluated critically for signs of generalized septicemia or other foci of infection.

Zoonotic Potential!!navigator!!

N/A

Pregnancy/Fertility/Breeding!!navigator!!

N/A

Abbreviations!!navigator!!

  • FTPI = failure of transfer of passive immunity
  • IgG = immunoglobulin G
  • NSAID = nonsteroidal anti-inflammatory drug
  • SAA = serum amyloid A
  • US = ultrasonography, ultrasound
  • WBC = white blood cell

Suggested Reading ⬆ ⬇

Adams SB, Fessler JF. Umbilical cord remnant infections in foals: 16 cases (1975–1985). J Am Vet Med Assoc 1987;190:316–318.

Edwards RB, Fubini SL. A one-stage marsupialization procedure for management of infected umbilical vein remnants in calves and foals. Vet Surg 1995;24:32–35.

Reef VB, Collatos CA. Ultrasonography of umbilical structures in clinically normal foals. Am J Vet Res 1988;49:2143–2146.

Reef VB, Collatos CA, Spencer PA, et al. Clinical, ultrasonographic and surgical findings in foals with umbilical remnant infections. J Am Vet Med Assoc 1989;195:69–72.

Smith M. Management of umbilical disorders in the foal. In Pract 2006;28:280–287.

Author(s) ⬆

Author: Margaret C. Mudge

Consulting Editor: Margaret C. Mudge