A Rare Case of Flood Syndrome and a Perspective on Management

Abstract

Flood Syndrome is a rare complication of cirrhosis accompanied by ascites. The syndrome is named for the exsanguination of ascitic fluid caused by the spontaneous rupture of an umbilical hernia. Very little data exists regarding its management as the literature is solely drawn from case reports. We present the case of a 42 year-old male with alcoholic cirrhosis presenting from home with Flood Syndrome treated in piecemeal fashion with complete resolution of symptoms. A 42 year-old male with alcoholic cirrhosis complicated by grade I esophageal varices, GI bleeds, massive ascites, and a large umbilical hernia presented to the ED with sudden and spontaneous rupture of his hernia leading to copious drainage of ascitic fluid from his umbilicus (Fig. 1) without inciting event. Over the first few hours the patient lost approximately 9 liters of exsanguinated ascetic fluid and was given IV albumin for fluid resuscitation to maintain intravascular oncotic pressure. The patient was evaluated by the gastroenterology and transplant surgery teams where a decision was made to perform an emergent transjugular intrahepatic portosystematic shunt (TIPS) to relieve portal pressures and subsequent intraabdominal pressure. The patient had resolution of symptoms following successful TIPS and was seen again by the surgery team to have an umbilical hernia repair. Flood syndrome is named for the “flood” of ascetic fluid that accompanies spontaneous rupture of an umbilical hernia and is a rare complication of cirrhosis with associated ascites. Cirrhotic patients with ascites have a 20% risk of umbilical hernia development during the course of their disease. In most cases (>75%), development of cutaneous infection and/or necrosis precedes hernia rupture. Any action that increases intra-abdominal pressure, such as coughing or vomiting, can precipitate this event. We present the case of a 42 year-old male presenting with Flood Syndrome treated in piecemeal with TIPS followed by successful surgical umbilical repair. Limited data exists regarding the treatment and is generally regarded as a surgical issue. We propose that these patients should be initially evaluated for TIPS to relieve the underlying intraabdominal pressure with subsequent referral for surgical repair shortly afterwards. We speculate that following reduction of portal pressure, complications of surgery such as wound dehiscence or recurrent episodes of exsanguination will be reduced.Figure: Necrotic Umbilical Hernia.