If the urachus persists after birth, it can form a urinary fistula that drains at the umbilicus This problem is ordinarily noted in the newborn period Older infants or children may present with drainage at the umbilicus caused by persistence of part of the urachus, even though connection with the bladder may be obliterated These urachal remnants also require surgical excision Persistent drainage from the umbilicus or infections near the umbilicus require surgical consultation and imaging to evaluate for omphalomesenteric ducts, urachal cysts, urachal fistulas Occasionally, the diagnosis is determined at surgery due to bowel obstruction related to the fibrous connections Suggested Readings and Key References Appendicitis Bachur RG, Callahan MJ, Monuteaux MC, et al Integration of ultrasound findings and a clinical score in the diagnostic evaluation of pediatric appendicitis J Pediatr 2015;166(5):1134–1139 Dibble EH, Swenson DW, Cartagena C, et al Effectiveness of a Staged US and unenhanced MR imaging algorithm in the diagnosis of pediatric appendicitis Radiology 2018;286(3):1022–1029 Duke E, Kalb B, Arif-Tiwari H, et al A systematic review and meta-analysis of diagnostic performance of MRI for evaluation of acute appendicitis AJR Am J Roentgenol 2016;206(3):508–517 Gorter RR, The SML, Gorter-Stam MAW, et al Systematic review of nonoperative versus operative treatment of uncomplicated appendicitis J Pediatr Surg 2017;52(8):1219–1227 Howell JM, Eddy OL, Lukens TW, et al American College of Emergency Physicians Clinical policy: critical issues in the evaluation and management of emergency department patients with suspected appendicitis Ann Emerg Med 2010;55(1):71–116 Kessler U, Mosbahi S, Walker B, et al Conservative treatment versus surgery for uncomplicated appendicitis in children: a systematic review and meta-analysis Arch Dis Child 2017;102(12):1118–1124 Kharbanda AB, Dudley NC, Bajaj L, et al.; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics Validation and refinement of a prediction rule to identify children at low risk for acute appendicitis Arch Pediatr Adolesc Med 2012;166(8):738–744 Kharbanda AB, Stevenson MD, Macias CG, et al.; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics