Flood Syndrome

Approximately 20% of patients with large-volume ascites will develop an umbilical hernia, representing
a confluence of increased intra-abdominal pressure and a weakened abdominal wall.5-8 A small fraction
of patients with large-volume ascites develop the severe complication of a ruptured umbilical hernia,
also known as “Flood syndrome,” described by Dr. Frank B. Flood in 1961.9 The surgical treatment of a
ruptured umbilical hernia in a patient with Child-Pugh class C cirrhosis is fraught with short- and long-
term complications and high mortality.10 Advances in surgical care have improved outcomes of general
surgery procedures in patients with cirrhosis.

Flood syndrome, named for the rush of fluid or flood that accompanies spontaneous rupture of an
umbilical hernia, is a rare complication of long-standing ascites and end-stage liver disease. Patients with
cirrhosis complicated by ascites have a 20% risk of umbilical hernia development during the course of
their disease. The umbilicus represents a weak portion of the abdominal wall as it interrupts the linea
alba. The peritoneum and overlying skin at the site of an umbilical hernia can break down completely,
leading to expulsion of intra-abdominal contents. Rupture of an umbilical hernia usually occurs with
drainage of ascitic fluid, which is given the term spontaneous paracentesis. Rupture may follow a sudden
increase in intra-abdominal pressure with coughing, vomiting, straining, or rising from a seated position.

Rarely, evisceration of the small intestine can occur. In most cases (80%), development of cutaneous
ulcerations precedes umbilical hernia rupture. Complications of umbilical hernia rupture include
incarceration of bowel, hypotension secondary to large-volume spontaneous paracentesis, and the
development of cellulitis, peritonitis, and sepsis. Ulceration or necrosis over an umbilical hernia should
be considered a dangerous sign, signaling impending rupture, and should prompt urgent surgical
referral.

Etiology / Causes

- Umbilical hernia

- Long term ascites

- End stage liver disease

Signs and Symptoms

- In umbilical hernias, a soft swelling or bulge near the navel (umbilicus). In babies who have an
umbilical hernia, the bulge may be visible only when they cry, cough or strain.

- Umbilical hernias in children are usually painless.

- Umbilical hernias that appear during adulthood may cause abdominal discomfort.
- In long term ascites: Increased abdominal size, increased weight, abdominal discomfort, shortness of
breath

- In end stage liver disease: itching , nausea, abdominal pain and bloating when fluid accumulates in the
abdomen

Management / Treatment and Medications

The optimal management of umbilical hernia in cirrhotic patient is not clear. There are always questions
about whether conservative management of wait and watch policy or early surgical option is better.
Conservative management can be complicated by incarceration or spontaneous rupture from necrosis
of overlying skin, forcing an emergency repair in patients who are at greater risk of complications after
such operations than after elective operation. Two studies found in the literature have evaluated the
results of management of umbilical hernias in patients with concurrent ascites and liver cirrhosis in
order to define optimal hernia treatment.

The first steps in managing these patients include parenteral antibiotics, applying an appropriate
dressing, and consulting surgery. Because nonsurgical management of a ruptured umbilical hernia is
associated with a mortality rate exceeding 60%, most patients are treated operatively with local tissue
or mesh repair.

In some cases, the patient could lose approximately 9 liters of exsanguinated ascetic fluid and was given
IV albumin for fluid resuscitation to maintain intravascular oncotic pressure. The patient was evaluated
by the gastroenterology and transplant surgery teams where a decision was made to perform an
emergent transjugular intrahepatic portosystematic shunt (TIPS) to relieve portal pressures and
subsequent intraabdominal pressure. The patient had resolution of symptoms following successful TIPS
and was seen again by the surgery team to have an umbilical hernia repair.

Patient often receives albumin, crystalloid, and piperacillin/tazobactam. An occlusive wound dressing
was applied. Surgery was consulted, and the patient was immediately taken to the operating room for
closure of the umbilical defect.