A rare case of flood syndrome: a case report of fatal complication of umbilical hernia in liver cirrhosis

Nagarajan Appusamy1, Arivarasan Kulandaivelu2

1Department of Pulmonology, Kauvery Hospital, Tiruchirappalli, Tamilnadu, India.

2Department of Gastroenterology, Kauvery Hospital, Tiruchirappalli, Tamilnadu, India.

*Correspondence: [email protected]

Abstract

Background: Flood syndrome refers to spontaneous umbilical hernia rupture followed by a sudden rush of ascitic fluid, which is a rare and potentially fatal complication of liver cirrhosis with gross ascites.

Case presentation: We present a case of 55-year-old gentleman with alcoholic cirrhosis and recurrent gross ascites who presented with sudden spontaneous rupture of umbilical hernia followed by a sudden gush of ascitic fluid from the hernia. He was admitted for hemodynamic stability followed by definitive surgical repair.

Conclusion: Flood syndrome is a rare sequela in the setting of refractory ascites and liver cirrhosis.

Keywords: Liver cirrhosis, Ascites, Umbilical hernia, Flood syndrome.

Background

Liver cirrhosis is commonly complicated with ascites (50% of cases) and umbilical hernia (20% of cases) [1]. Sudden and spontaneous rupture of umbilical hernia with a resultant abrupt rush of ascitic fluid referred to as Flood syndrome, is a rare but potentially fatal complication in a patient with liver cirrhosis and long-standing ascites [2]. The reported factors that explain the mechanism of spontaneous rupture of umbilical hernia in cirrhosis include the inherent weakness of the abdominal wall and umbilical vein dilatation and varices formation at the umbilical level secondary to hypoalbuminemia and portal hypertension, respectively, and continuous increased intra-abdominal pressure from ascitic fluid [3–6]. Among the complications of flood syndrome that have been reported include peritonitis, cellulitis, sepsis, bowel strangulation, evisceration, and death.

Case Presentation

A 55-year-old man with a medical history of alcoholic liver cirrhosis with recurrent massive ascites came to the emergency room with complaints of sudden gush of approximately 4–5 L of fluid from his pre-existing umbilical hernia today morning few hours before presentation. He felt relieved from the tense abdomen following spontaneous leakage of fluid from the umbilical hernia. He denied any prior trauma, abdominal pain, bleeding, or similar episode in the past. He was on modified antituberculosis treatment for right-sided recurrent massive exudative, pleural effusion after the pleural biopsy report of the granulomatous lesion.

Physical examination revealed a distended abdomen without any tenderness or guarding. There was an umbilical hernia with a non-bleeding ulcer with protrusion (Fig. 1) at the tip of the hernia from which straw-colored fluid was actively draining. Otherwise, he was hemodynamically stable, without any signs of hepatic encephalopathy. The wound was cleaned in a sterile gauze dressing, and he was admitted to the gastroenterology department for further management. He was treated with intravenous fluids, antibiotics, and other supportive medications. The patient was improved and discharged. He was planned for surgical repair on follow-up.

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Discussion

Flood syndrome described as a sudden gush of fluid from spontaneous umbilical hernia rupture, is a rare and life-threatening complication of chronic ascites and end-stage liver disease [7]. A mortality rate as high as 30% has been reported. This is due to the interruption of linea alba at the umbilicus resulting in a site of weakness at the anterior abdominal wall, allowing protrusion of peritoneum, fluid, omentum, or even bowels from the raised intra-abdominal pressure.

Complications that may arise from Flood syndrome include bacterial peritonitis, cellulitis of the abdominal wall, sepsis, incarceration, or strangulation of bowel and renal or hepatic failure. Loss of a large volume of ascitic fluid may also lead to hemodynamic instability and death.

The prevention of umbilical hernia rupture is dependent on the optimal management of underlying ascites in cirrhotic patients. Treatment options include umbilical herniorrhaphy, transjugular intrahepatic portosystemic shunting (TIPS, Peritoneovenous Drainage – PVS). Other alternative techniques include injection of fibrin glue into the defect to stop the ascitic leakage and placement of pigtail drain to allow the ulcer to heal by itself.

Conclusion

Flood syndrome is a rare and potentially life-threatening complication in patients with end-stage liver disease and long-standing ascites. There is no standard guideline with regards to the management of Flood syndrome. A consensus has been reached to follow conservative measures to prevent the occurrence of disease and tailor the surgical options based on the severity of the presentation.

References

  • Choo EK, McElroy S. Spontaneous bowel evisceration in a patient with alcoholic cirrhosis and an umbilical hernia. J Emerg Med. 2008;34:41–3.
  • Flood FB. Spontaneous perforation of the umbilicus in Laennec’s cirrhosis with massive ascites. N Engl J Med. 1961;264:72–4.
  • Belghiti J, Durand F. Abdominal wall hernias in the setting of cirrhosis. Semin Liver Dis. 1997;17:219–26.
  • Saleh F, Okrainec A, Cleary SP, Jackson TD. Management of umbilical hernias in patients with ascites: development of a nomogram to predict mortality. Am J Surg. 2015;209:302–7.
  • de Goede B, van Kempen BJ, Polak WG, de Knegt RJ, Schouten JNL, Lange JF, et al. Umbilical hernia management during liver transplantation. Hernia. 2013,17:515–9.
  • McAlister V. Management of umbilical hernia in patients with advanced liver disease. Liver Transpl. 2003;9:623–5.
  • Shankar DA, Itani KMF, O’Brien WJ, Sanchez VM. Factors associated with long-term outcomes of umbilical hernia repair. JAMA Surg. 2017,152:461–6.

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