2349 Flood Syndrome, a Rare Complication of Cirrhosis

Abstract

INTRODUCTION: “Flood syndrome,” also known as spontaneous umbilical hernia rupture, is a rare complication of end-stage liver disease and persistent ascites. We present a case of a patient who developed Flood syndrome prompting emergent surgical management. CASE DESCRIPTION/METHODS: A 63-year-old man with cryptogenic cirrhosis and ascites presented with worsening diffuse abdominal pain. Physical exam revealed a massively distended abdomen with generalized tenderness and a large umbilical hernia (UH) with ulceration of the overlying skin. Abdominal CT scan revealed large, loculated, abdominopelvic ascites with a large ventral hernia containing ascites (Figure 1). Despite undergoing two large-volume therapeutic paracentesis, he experienced spontaneous rupture of an ulcerated UH while attempting to defecate during this hospitalization. Likely greater than 10 L of ascitic fluid poured out leading to hypotension and prompt emergent exploratory laparotomy with repair of the defect in the abdominal wall. DISCUSSION: UH is seen in up to 20% of patients with cirrhosis and persistent ascites [1]. It is the result of the chronically weakened state of the abdominal wall surrounding the umbilicus in the setting of increased intra-abdominal pressure. Flood syndrome can occur when the tense pressure of ascites leads to spontaneous rupture of an umbilical hernia site with drainage of a large volume of ascitic fluid. It is a serious condition, with a mortality of over 60%. Rupture of an umbilical hernia site in Flood syndrome can be provoked by vomiting, coughing, or straining with defecation. In Flood syndrome, treatment begins with fluid resuscitation and antibiotics to prevent infection. Once stable, emergent surgical repair of the abdominal wall defect is essential. Non-surgical management is not advised and is associated with higher mortality. To prevent complications and improve mortality, these patients should be treated immediately with surgical intervention [2].

Flood Syndrome

“…Flood syndrome refers to the exsanguination of ascitic fluid following the spontaneous rupture of an umbilical hernia. Due to the rarity of this condition, there is no standardized treatment protocol [9], with current literature being limited to case Treatment of Flood syndrome typically begins with fluid resuscitation and antibiotics [6], wound care such as sterile occlusive dressing application [10] or placement of an ostomy pouch [1]. Non-invasive management also includes nutritional optimization, antibiotics, avoiding hepatotoxic medications [8].…”

“…Flood in 1961 [4]. It is a rare complication of liver cirrhosis with ascites and is frequently (> 75%) preceded by cutaneous infection and/or skin necrosis or ulceration and precipitated by raised intra-abdominal pressure [5], which includes vomiting, coughing, and straining with defecation [6].…”