Sister Mary Joseph nodule revisited !

Examination:
         She was conscious , oriented hemodynamically stable and  had no icterus or lymphadenopathy. Her abdominal examination revealed an umbIlical nodule around 4cms with serosanguinous discharge  and  it had  firm margins  Fig 1 

Fig 1 UmbIlical nodule SJN

  Her abdominal examination revealed hepatomegaly 2 cms below costal margin .There was no ascites .Her systemic examination was normal .
Evaluation: 
              The hemogram revealed hemoglobin of  10.8 gm/dl and her TLC and platelets were normal . Her renal functions and liver functions were normal .Keeping in view non healing nature of this umbilical swelling , biopsy was done from the edge of the nodule which  showed metastatic adenocarcinoma .Fig2 .Hence the nodule proved to be sister Mary Joseph nodule .

Fig 2 Biopsy from umbilical nodule

Later CT scan abdomen was done Fig 3 which revealed gallbladder mass .Patient had an inoperable carcinoma of gall bladder and she later developed progressive cholestasis and deep Jaundice and  succumbed   to her illness unfortunately .

Fig 3 CT abdomen showing carcinoma Gallbladder  (arrow )

Teaching message :   
          “Non healing ulcers must be biopsied” . 
Umbilical metastasis is named Sister Mary Joseph nodule (SJN) The name is after the  vigilant head nurse working in Mayo clinic nearly a century ago .She observed  patients with this findings were having advanced malignancy . Her observation was published in 1949 in Hamilton Baily  .
         Men  with SJN usually have GI malignancies while women with SJN have ovarian malignancies . It can occasionally occur due to lung malignancies even.
       The size may range few cms and even as long as 10 cms have been recorded . This finding reflects metastasis through lymphatic channels or through peritoneum or through embryological remnants . 

Further Reading:     Gall bladder cancer