Pictorial Case Study - Sister Mary Joseph nodules

Contributed by Dr Gwen Lewis, a GP in Windsor, Berkshire.

Sister Mary Joseph nodule: a palpable nodule that bulges into the umbilicus as a result of metastasis of a pelvic or abdominal malignancy (Photograph: NZ Dermnet)

The case
A 48-year-old woman presented in the surgery with a two-week history of mild lower abdominal discomfort and bloated sensation. The discomfort was constant, but otherwise she felt generally well.

Her appetite was good and she had no bowel or urinary symptoms. Her periods were regular. She was not on any medication and had no past medical history of note, other than three normal pregnancies. She did mention that she had lost 3-4kg in weight, but she had been trying to do so by dieting.

On examination, she looked well and was not obviously in discomfort. Abdominal examination revealed an umbilical lump measuring 2.5cm by 2cm and the presence of generalised lower abdominal tenderness. She was menstruating, so vaginal examination was not carried out.

What is the diagnosis?
The diagnosis is that of a Sister Mary Joseph nodule - a visible and palpable nodule that bulges into the umbilicus as a result of metastasis of a pelvic or abdominal malignancy.

Fifty per cent of these nodules are seen in cases of GI malignancy, while 25 per cent are seen in gynaecological malignancies, particularly ovarian and uterine cancers.

The patient underwent an urgent pelvic ultrasound examination which confirmed the diagnosis of ovarian cancer and she was referred under the two-week rule to a gynaecologist specialising in oncology. She is currently undergoing active treatment.

The nodule is named after Sister Mary Joseph Dempsey, who was the surgical assistant of Dr William J Mayo in Rochester, Minnesota, from 1890 to 1915. She alerted Dr Mayo to the phenomenon and so it was given her name.

Possible differential diagnoses

  • Epigastric hernia
  • Paraumbilical hernia
  • Umbilical hernia

Differential diagnosis
Epigastric hernia

  • About 3-5 per cent of people develop an epigastric hernia.
  • Common between the ages of 20 and 50 years, they occur more often in men than in women.
  • An epigastric hernia occurs as a result of a weakness in the junction of the right and left rectus abdominis muscles at the linea alba.
  • A small piece of fat squeezes through the weakness, causing a swelling.
  • The features in a symptomatic patient may include pain, an abdominal mass and bloating, nausea and vomiting.
  • The hernia is aggravated by eating.
  • Most epigastric hernias should be repaired - small ones are likely to incarcerate and large ones are often symptomatic and unsightly.

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