Case Presentation: A 68-year-old with a history of End Stage Liver Disease (ESLD) presented with 3 weeks of worsening abdominal distention after stopping her home diuretics. In the ED, vital signs were stable. Labs were notable for bilirubin of 3.6 with direct bilirubin of 1.3, albumin of 2.2, and platelets of 74. The patient was classified as Child’s Pugh Class C and had a MELD-Na score of 25. She underwent therapeutic paracentesis with removal of 5 liters of ascitic fluid. Serum Ascites Albumin Gradient was 1.8 which is consistent with portal hypertension. She was admitted for management of decompensated cirrhosis.On admission, the patient disclosed 2 weeks of foul-smelling fluid weeping from her umbilicus. Physical exam revealed a distended abdomen and a large umbilical hernia with a violaceous hue. The inferior aspect of the hernia was ulcerated and draining clear fluid. CT abdomen demonstrated a fascial defect that correlated with the area of drainage on exam. General Surgery was consulted due to concern for impending Flood Syndrome. Due to high risk of spontaneous rupture, the surgical team recommended urgent umbilical hernia repair. Gastroenterology was engaged to optimize the patient prior to surgery. She received 3 additional large volume paracenteses, completed treatment for spontaneous bacterial peritonitis with IV antibiotics, and had transjugular intrahepatic portosystemic shunt (TIPS) placement. The patient then underwent primary repair of the umbilical hernia with umbilicoplasty and was ultimately discharged on spironolactone.
Discussion: Flood Syndrome is a rare but important complication of ESLD. 20% of cirrhotic patients with longstanding ascites will develop an umbilical hernia over time [1]. In such patients, skin breakdown over the hernia can lead to ulceration, necrosis, and ultimately spontaneous rupture of the hernia. Flood Syndrome is described as the sudden loss of skin integrity leading to hernia rupture and associated large volume paracentesis. Complications of Flood Syndrome include bowel incarceration, hypotension due to rapid volume loss, and infections such as peritonitis, cellulitis, and sepsis. Non-operative management of the ruptured hernia is associated with a high mortality rate, ranging anywhere from 60-80% [1]. Urgent hernia repair reduces the mortality rate significantly. Nearly 80% of patients with Flood Syndrome will have skin ulceration or necrosis on exam. Such skin findings should prompt General Surgery evaluation for consideration of hernia repair.
Conclusions: Hospitalists frequently care for patients with decompensated cirrhosis. 1 in 5 ESLD patients with ascites will develop an umbilical hernia. Although rare, Flood Syndrome is a known complication in ESLD patients with longstanding ascites and umbilical hernias. Skin ulceration or necrosis over the hernia is a common finding in patients at risk for spontaneous rupture. Such exam findings should expedite surgical consultation, as definitive surgical management is the most appropriate treatment for patients at risk of Flood Syndrome.