Recanalization of the Paraumbilical Vein Mimicking an Umbilical Hernia: A Case Report

Portal hypertension associated with chronic liver disease may lead to recanalization of the paraumbilical vein and the development of portosystemic collateral vessels, classically manifesting as caput medusae. Although this finding is uncommon in contemporary clinical practice, dilated paraumbilical collaterals may present as an umbilical protrusion and mimic an umbilical hernia. Recognition of this condition is crucial because inadvertent surgical injury to these vessels may result in severe, potentially life-threatening hemorrhage. We report a case of a 77-year-old male with compensated hepatitis C virus-related cirrhosis (Child-Pugh class A; Model for End-Stage Liver Disease (MELD) score 10) who presented with an asymptomatic, reducible 2 cm umbilical protrusion initially considered an umbilical hernia. Doppler ultrasonography of the abdominal wall was performed and demonstrated a patent, recanalized paraumbilical vein communicating with the left portal vein branch and extending into the superficial abdominal wall, with drainage toward the epigastric and femoral venous systems. These findings were consistent with extensive portosystemic collateral circulation, representing caput medusae and accounting for the apparent umbilical protrusion. Recognition of the vascular nature of the lesion prevented an unnecessary surgical intervention and its associated hemorrhagic risk. This case emphasizes the importance of considering portosystemic collateral vessels in the differential diagnosis of umbilical protrusions in patients with chronic liver disease. Differential diagnoses include true umbilical hernia, isolated abdominal wall varices, venous malformations, and metastatic umbilical nodules such as Sister Mary Joseph's nodule. Doppler ultrasonography is a readily accessible, noninvasive method for characterizing the lesion, demonstrating vascular flow, identifying communication with the portal venous system, and defining the extent of collateral circulation. Therefore, vascular imaging should be considered before surgical repair of an apparent umbilical hernia in patients with cirrhosis or other conditions associated with portal hypertension. Caput medusae may present as an umbilical protrusion mimicking a hernia, and careful clinical assessment combined with Doppler ultrasonography is essential for accurate diagnosis and prevention of potentially catastrophic surgical hemorrhage.