Abstract
IntroductionThe incidence of hernias is increased in patients with alcoholic liver disease with ascites. To the best of our knowledge, this is the first report of an acute rise in intra-abdominal pressure from straining for stool as the cause of a ruptured umbilical hernia.Case presentationAn 81-year-old Caucasian man with a history of alcoholic liver disease presented to our emergency department with an erythematous umbilical hernia and clear, yellow discharge from the umbilicus. On straining for stool, after initial clinical assessment, our patient noted a gush of fluid and evisceration of omentum from the umbilical hernia. An urgent laparotomy was performed with excision of the umbilicus and devitalized omentum.ConclusionWe report the case of a patient with a history of alcoholic liver disease with ascites. Ascites causes a chronic increase in intra-abdominal pressure. A sudden increase in intra-abdominal pressure, such as coughing, vomiting, gastroscopy or, as in this case, straining for stool can cause rupture of an umbilical hernia. The presence of discoloration, ulceration or a rapid increase in size of the umbilical hernia signals impending rupture and should prompt the physician to reduce the intra-abdominal pressure.
Highlights
The incidence of hernias is increased in patients with alcoholic liver disease with ascites
We report the case of a patient with a history of alcoholic liver disease with ascites
Intra-abdominal pressure is chronically elevated in various disease processes including ascites, large cysts and large neoplastic formations [7,8,9] which increase the likelihood of hernias
Summary
There has been considerable debate in the literature as to the timing of umbilical hernia repair in patients with alcoholic liver disease and ascites. Other studies [19,20] have shown improved outcomes in the elective setting but require intensive pre-operative optimization. Some experts [21] would operate in the elective setting for Child’s A cirrhosis and when complications of umbilical hernias develop an urgent repair is indicated. The use of fibrin glue is currently restricted to patients declared unfit/unwilling to undergo operative repair [23]. A recent expert consensus study suggested a decrease in the suitability of mesh repair as the Child’s score increases [21]. More evidence is required, and cases should be considered individually, to determine the most effective timing of umbilical hernia repair. PCN wrote the manuscript and performed a final review.
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