Spontaneous umbilical hernia rupture with omental evisceration and Flood syndrome

Abstract

Cirrhotic patients are at increased risk of developing umbilical hernias. Many cirrhotic patients’ umbilical hernias are not repaired electively due to concerns for high perioperative morbidity and mortality. This case report aims to inform clinicians about the unique challenges that arise during emergency management of umbilical hernias in the cirrhotic patient. A 59-year-old male with Child-Turcotte-Pugh grade B cirrhosis presented to our hospital with an incarcerated umbilical hernia that spontaneously ruptured with large volume ascitic leak (known as Flood syndrome) and omental evisceration. The patient underwent emergency sutured umbilical hernia repair, and required a prolonged post-operative stay in the hospital intensive care unit after suffering from complications including spontaneous bacterial peritonitis, anaphylaxis to antibiotic treatment, aspiration pneumonia, encephalopathy and worsening ascites. He eventually made a good recovery and underwent rehabilitation prior to discharge home. This case highlights the rare complication of spontaneous omental evisceration of an umbilical hernia in the cirrhotic patient and details its subsequent management. It is important to note that elective hernia repair after medical optimisation is high risk in the cirrhotic patient, but is recommended to avoid the high perioperative mortality and morbidity associated with emergency repair.

Flood Syndrome

“…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]. This is followed by consideration of methods for reducing ascitic pressure on the hernia wound, and hernia defect repair including use of fibrin glue [26,27] or umbilical herniorrhaphy (either elective after medical optimization or emergency) [1].…”

“…Thus, in suitable patients, umbilical herniorrhaphy without mesh is recommended and should be followed by ascites control [29] as mentioned above. The repair is ideally performed after medical optimization [8] unless in emergency situations such as peritonitis [13], bowel incarceration or evisceration [14]. This is to minimize postoperative complications which include wound infection or dehiscence, ascitic fluid leakage, liver failure, bleeding, ileus, encephalopathy and hernia recurrence [1,15].…”

“…It is important to recognize Flood syndrome as complications such as bowel incarceration, hemodynamic instability, electrolyte abnormalities and infection including cellulitis and peritonitis [7] can arise, amounting to a mortality rate of 30% [8]. This case report describes the progress and management of a patient with Flood syndrome admitted to a community hospital.…”