Management of Flood syndrome: What can we do better?

Abstract

Approximately 20% of cirrhotic patients with ascites develop umbilical herniation. These patients usually suffer from multisystemic complications of cirrhosis, have a significantly higher risk of infection, and require accurate surveillance– especially in the context of the coronavirus disease 2019 pandemic. The rupture of an umbilical hernia, is an uncommon, life-threatening complication of large-volume ascites and end-stage liver disease resulting in spontaneous paracentesis, also known as Flood syndrome. Flood syndrome remains a challenging condition for clinicians, as recommendations for its management are lacking, and the available evidence for the best treatment approach remains controversial. In this paper, four key questions are addressed regarding the management and prevention of Flood syndrome: (1) Which is the best treatment approach–conservative treatment or urgent surgery? (2) How can we establish the individual risk for herniation and possible hernia rupture in cirrhotic patients? (3) How can we prevent umbilical hernia ruptures? And (4) How can we manage these patients in the conditions created by the coronavirus disease 2019 pandemic?

Flood syndrome following right-sided heart failure: a case report

“…The elevated intraabdominal pressure caused by ascites leads to umbilical herniation; further compression against the skin causes its necrosis and thinning, which leads to eventual rupture. Thus, Flood syndrome is established [ 1 , 5 ]. We found no previous record of Flood syndrome following ascites, caused by right-sided heart failure.…”

“…The most common complications of Flood syndrome are fluid imbalance, infection and bowel evisceration/incarceration [ 5 ]. No infection, serious fluid imbalance or immediate bowel incarceration was seen in our patient.…”

“…An ostomy bag can be used to collect further ascites fluid. Secondly, management of ascites is needed to prevent later wound dehiscence and evisceration [ 5 ]. These recommendations were followed in the present case, despite its different essential pathology.…”

“…Yet, we believe that surgical treatment of Flood syndrome following right-sided heart failure is also a safe option, as cirrhosis brings with it coagulopathy and thrombocytopenia. Primary closure with non-absorbable sutures is the surgical method of choice, as mesh hernioplasty is associated with higher risk of infection [ 2 , 5 ]. In our case surgery was needed due to the later occurrence of strangulated hernia; the hernia was suture repaired.…”

“…Optimal management of this rare case is still a matter of debate [ 2–4 ]. The cause of ascites in Flood syndrome is almost always liver cirrhosis [ 5 ]. In this case report we provide insight into our experience with a rare case of Flood syndrome following right-sided heart failure and present a rare video of umbilical hernial leakage.…”