Flood syndrome: a rare case of spontaneous rupture of umbilical hernia in a cirrhotic patient

Abstract

INTRODUCTION

Flood syndrome is a rare and potentially fatal complication of long-standing ascites resulting from a spontaneous rupture of an umbilical hernia. Peritonitis becomes a feared complication due to the open defect in the abdominal wall. However, surgical intervention is often complicated with the risk of high mortality due to the patient populations’ decompensated liver cirrhosis.

CASE DESCRIPTION

We present the case of a 67-year-old male with a medical history of diastolic heart failure, cocaine abuse, hepatitis C and cirrhosis secondary to daily alcohol consumption (MELD 15, Child-Pughes B) who presented to the emergency department with spontaneous rupture of an umbilical hernia 1 h prior to presentation. The patient had previously been seen for a small ulcer at the inferior base of the umbilicus, which was sutured closed with plans for surgical intervention electively on an outpatient basis. The patient did undergo paracentesis every 2–3 weeks for management of ascites. Pending scheduling of the intervention, the patient presented with spontaneous rupture of the umbilicus through an ~3 cm skin defect causing continued flow of ascitic fluid from the umbilicus. Due to the large size of the defect, ascitic fluid continued to pour from the umbilical hernia. The defect was sufficiently closed with two figure of eight stitches followed by the placement of an abdominal binder, allowing time for the patient to be transferred to a specialized care center for definitive treatment. Following transfer, a computed tomography of the abdomen and pelvis was obtained with evidence of an umbilical hernia containing serpiginous loculated ascites with rim enhancement. Preoperatively the patient was appropriately corrected for any lab-based abnormalities. Intraoperatively, a 10 cm elliptical incision was made to drain the multiloculated hernia sac, the hernia sac was ligated, nearly 4 L of ascitic fluid was suction with infusion of albumin due to transient hypotension. The peritoneum was with a running 3–0 PDS, the fascia closed in a vest-over-pants manner using interrupted 0 prolene sutures, the dermis was closed with a running 3-0PDS sutures and the skin closed with a 2–0 nylon horizontal mattress suture. The patient presented in the case was not a candidate for liver transplantation due to ongoing ethanol use. Outpatient follow-up information included Q2week paracentesis PRN, establishment with hepatology for ongoing surveillance, a low sodium diet, outpatient esophagogastroduodenoscopy to screen for varices.

DISCUSSION

There are no formal guidelines regarding management and treatment of flood syndrome, a rare complication of long-standing ascites with a mortality rate reaching ~30% [1] Review of the limited literature does provide several different methods of successful management. One case described utilization of ostomy appliances placed around hernia site with subsequent pigtail peritoneal drain allowing the umbilical ulcer to heal; however, the course of treatment was complicated with infection requiring removal of the drain [2] Elective repair is the most effective choice of repair, requiring control of ascites prior to and following surgical intervention. Review of the literature demonstrates that cirrhotic patients undergoing umbilical hernia repair have a high rate of intensive care unit admission, longer length of stay, aspiration pneumonia, pulmonary compromise, myocardial infection and metabolic derangement. One randomized study evaluated mesh vs tissue repair in cirrhotic patients with evidence of lower rates of recurrence in the mesh arm, 2.7% vs 14.2%, respectively [3] Morbidity is significantly recued in cirrhotic patients with elective umbilical hernia repairs [1, 4, 5] Emergent surgery should take place at experienced centers with aggressive control of preoperative electrolytes, diuretic therapy, percutaneous paracentesis and appropriate postoperative monitoring [5] Another case report proposed patients be initially evaluated for Transjugular intrahepatic protosystemic shunt in order to relieve portal pressures and subsequent intraabdominal pressures followed by a surgical umbilical hernia repair through the presentation of successful management of a 42-year-old male with flood syndrome [6]

CONCLUSION

In conclusion we present the case of a patient that was temporized in our care, and transferred to a specialized center for definitive treatment of flood syndrome. We highlight the necessity for awareness of temporizing options of the patient, and methods for successful treatment of this rare and potentially fatal complication of cirrhosis.

CONFLICT OF INTEREST STATEMENT

None declared.

FUNDING

None.

References