A 55-year-old female with Child-Pugh1 Grade C cirrhosis and an umbilical hernia presented with 5 days of fluid leakage from her hernia site. Four months prior to presentation, she had developed tense ascites requiring serial paracentesis. Her hernia became blue and ulcerated, and intermittently drained small amounts of fluid; however, the opening had always closed. Five days prior to admission, she experienced a large gush of ascites from her umbilicus (correlating to an 8 kg weight loss), and the wound never scabbed over. Unable to contain the leak, she presented to the emergency department.
On exam, the hernia was 3×2 cm, with overlying induration and a 0.5 cm punctate hole draining straw-colored fluid. Laboratory studies revealed thrombocytopenia, worsening hyponatremia, hepatic injury from recent alcohol use and cirrhosis, and most notably an acute kidney injury (AKI) with creatinine elevation to 1.8 from 0.7 mg/dL. AKI prevented management of ascites via diuresis; additionally, the patient was a poor candidate for TIPS given prior encephalopathy and MELD-Na2 score of 28. She received cefepime and vancomycin for prophylaxis against peritonitis, and albumin to maintain intravascular volume. The hernia was surgically repaired by primary closure, and a pigtail drain was placed to drain ascitic fluid and minimize collection around the repair site. On resolution of the AKI, diuretic therapy was initiated. The patient experienced no adverse effects, including infection, critical hypotension, or renal failure.
Discussion:
Umbilical hernias develop in up to 20% of patients with ascites in the setting of hepatic cirrhosis, resulting from increased intra-abdominal pressure.3 Hernia rupture and ‘auto-paracentesis’ is a rare sequela, with significant morbidity and mortality.
First reported in the literature in 1901,3 this unusual complication is often referred to as Flood syndrome, both as a descriptor of the outpouring of fluid on rupture, and in eponymous attribution to Frank Flood, the first to publish an analysis of common complications and management approaches for the condition.4–6 [O1]
With conservative management alone, mortality is as high as 60-80%. Urgent surgical herniorrhapy with primary closure (without mesh)7 is the intervention of choice, and reduces mortality rates to 6-20%.3,8 Post-operative control of ascites is critical to the success of repairs, though the approach (diuresis, drain placement, serial paracentesis, or TIPS) should be based on each patient’s unique clinical circumstance.8
Conclusions:
Cirrhotic patients with an umbilical hernia should be referred for elective surgical repair, in order to prevent the development of rupture or other complications.7
Discoloration or ulceration of the hernia occurs in up to 80% of patients prior to rupture.9 This clinical finding should prompt urgent intervention to reduce intra-abdominal pressure, and surgical repair is indicated to avoid the morbidity and mortality associated with rupture.