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Year : 2022  |  Volume : 5  |  Issue : 4  |  Page : 218-220

Emergency presentation of Flood syndrome requiring immediate repair of umbilical hernia: A case report

Digestive Division, Department of Surgery, Fatmawati Central General Hospital, Jakarta, Indonesia

Date of Submission19-Sep-2022
Date of Decision01-Oct-2022
Date of Acceptance08-Oct-2022
Date of Web Publication24-Dec-2022

Correspondence Address:
Adianto Nugroho
Digestive Division, Department of Surgery, RSUP Fatmawati, Jl. RS. Fatmawati Raya No. 4, Jakarta 12430
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_42_22

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Long-term ascites and liver illness in its last stages might occasionally result in Flood syndrome. The abrupt surge of ascitic fluid that occurs along with an umbilical hernia that spontaneously ruptures gives rise to the syndrome's name. We described a patient who had cirrhosis and valvular heart disease in the past and had Flood syndrome with intestinal evisceration. To stop the progression of intestinal necrosis and septic consequences, immediate surgery to reduce the eviscerated bowel and mesh reinforcement was performed. In summary, Flood syndrome is a serious condition that needs to be treated very away, much like other forms of intestinal evisceration. The efficient management of comorbid disorders is essential for a better therapeutic outcome.

Keywords: Bowel evisceration, Flood syndrome, massive ascites, umbilical hernia

How to cite this article:
Nugroho A, Permata Y, Jamtani I, Widarso A, Saunar RY. Emergency presentation of Flood syndrome requiring immediate repair of umbilical hernia: A case report. Int J Abdom Wall Hernia Surg 2022;5:218-20

How to cite this URL:
Nugroho A, Permata Y, Jamtani I, Widarso A, Saunar RY. Emergency presentation of Flood syndrome requiring immediate repair of umbilical hernia: A case report. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2023 Jan 28];5:218-20. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/4/218/365093

  Introduction Top

Uncommon but possibly fatal, spontaneous rupture of an umbilical hernia can occur in patients with extensive ascites, frequently caused by cirrhosis or cardiac conditions.[1],[2],[3] Frank B. Flood, from whom the term “Flood syndrome” was derived, was the first to describe this specific illness.[4] We reported a case of Flood syndrome involving eviscerated bowel that required rapid surgical repair.

  Case Presentation Top

A 49-year-old man, with body mass index (BMI) of 30.1, came to the emergency department with expulsion of bowel through perforated navel since 8 h prior to admission [Figure 1]. We can appreciate a bulging at the cranial part as a part of the complex hernia defect. He had a history of repeated ascites aspiration, 9 L each time, in the last 6 months. Only after that frequent aspiration did he realize the enlargement of the lump in his navel. The patient had a history of heart valve disorders, diabetes mellitus, hypertension, and chronic kidney disease but without a history of hemodialysis.
Figure 1: Umbilical hernia with eviscerated bowel

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He was presented with a blood pressure of 150/90 mmHg, heart rate of 104 bpm, and respiratory rate 22 times per minute with the oxygen of 12 lpm through a nonrebreathing mask. There was no fever, and the patient was fully aware. We can appreciate an evisceration of a small bowel loop from an opening in the navel, without any area of necrosis. A sign of ascites was present at the time of examination. His laboratory values showed anemia (Hb = 10.7 g/dl), leukocytosis (10,400 g/dl), and increased creatinine (2.26 mg/dl) with normal random blood glucose level of 111 g/dl.

After adequate resuscitation, the patient was then subjected for an immediate surgical repair under general anesthesia. The size of hernia defect was 6 cm × 5 cm. No bowel resection was performed because no necrosis was found. After irrigating the bowel and draining 4,200 ml of ascites fluid, the hernia defect was closed with onlay repair using a 10 cm × 10 cm polypropylene mesh, and a pig tail catheter was inserted [Figure 2]. The operating time was 65 min, and care was continued in the intensive care unit.
Figure 2: A, Reduced bowel to the peritoneal cavity; B, mesh reinforcement of the hernia defect

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  Discussion Top

Flood syndrome is a condition in which the umbilical hernia spontaneously ruptures together with the outflow of ascitic fluid, giving rise to the term spontaneous paracentesis.[1],[2] Coughing, vomiting, straining, or getting up from a seated position may cause an abrupt rise in intra-abdominal pressure, which may be followed by rupture.[5] The frequent aspiration of ascites, which results in abrupt fluctuations in pressure, the imprisonment of the intestine, cellulitis, peritonitis, and sepsis are risk factors. Skin ulceration or excoriation is a symptom of a process leading to rupture and a warning indication of approaching rupture.[6],[7],[8] As evidenced in this case report, the small intestine can occasionally be eviscerated.

The therapeutical approach to this potentially life-threatening complication is still controversial. Chatzizacharias et al.[9] showed in their case series that the surgical timing is not critical as long as an appropriate optimization of the patient condition is undertaken. The latter is accomplished in a variety of ways, including prophylactic antibiotic therapy to prevent ascitic fluid superinfection, fluid resuscitation, routine paracentesis, high-dose diuretic therapy, and fluid resuscitation, but first and foremost with the proper ascites management by setting up porto-venous shunt (PVS) or better yet, a transjugular intrahepatic portosystemic shunt (TIPS) in the preoperative setting, which proved to be successful in up to 92% of cases. An alternative bridging approach enabling a proper optimization of the patient prior to surgery could be attempted with local treatment at the site of the rupture. According to D’Orazio et al.,[1] the temporary closure of the cutaneous defect with fibrin glue may be a useful strategy for stabilizing the patient and lowering the risk of complications during and after surgery. Chikamori et al.[2] in their case report also showed the utilization of partial splenic embolization and temporary percutaneous peritoneal drainage in the management of Flood syndrome.

The majority of authors assert that a primary closure using nonabsorbable sutures appears to be the most effective surgical strategy. A single randomized research involving 80 patients found a lower rate of hernia recurrence in cirrhotic patients with complicated UHs who used a synthetic mesh.[10] Even though the incidence of postoperative complications was not different, it has been demonstrated that the use of meshes in cirrhotic patients significantly reduces the rate of recurrence, is capable of inducing an amazing inflammatory process, and enables a more stable strengthening of the abdominal wall than the conventional suture method.[1]

Examples of postoperative issues include infection at the surgical site, ascitic fluid leakage, liver failure, fluid deficiency, and hernia recurrence. The mortality rate for urgent hernia repair is 6%–20%, according to reports. Hemodynamic instability and death could also ensue from significant ascitic fluid loss. The main therapeutic goals in an emergency setting should be hemodynamic stabilization and avoiding infectious consequences. After cleaning the area, place a sterile dressing on it. The patient should start taking a broad-spectrum antibiotic in order to prevent bacterial peritonitis. The patient should also receive intravenous (IV) fluids if there has been a substantial amount of spontaneous paracentesis because there may have been hemodynamic instability.[10],[11]

General long-term management techniques include dietary adjustments, continued patient and family education, and avoiding alcohol, smoking, constipation, and heavy lifting. The main method of preventing umbilical hernia (UH) development and rupture, especially in cirrhotic patients, is the most effective ascites control using medical therapy or routine paracentesis.[10] Furthermore, it is critical to regularly monitor individuals with ascites and to consider elective UH repair as soon as a herniation manifests itself. By doing so, surgical complications may occur less frequently, and UH rupture may be avoided. In the past, the watch-and-wait strategy was applied to patients with ascites and UHs, and surgery was only performed when complications arose.

In summary, Flood syndrome is a life-threatening illness that requires prompt treatment, just like other types of intestinal evisceration. The key to a successful therapeutic outcome is the effective management of comorbid conditions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

D’Orazio B, Geraci G, Corbo G, Di Vita G Spontaneous rupture of umbilical hernia in end stage liver disease patient: Injection of fibrin glue as a temporary solution. Clin Ter 2021;172:504-6.  Back to cited text no. 1
Chikamori F, Mizobuchi K, Ueta K, Takasugi H, Yukishige S, Matsuoka H, et al. Flood syndrome managed by partial splenic embolization and percutaneous peritoneal drainage. Radiol Case Rep 2021;16:108-12.  Back to cited text no. 2
Murruste M, Kase K, Kivilo M, Lepner U Flood syndrome following right-sided heart failure: A case report. J Surg Case Rep 2022;2022:rjab631.  Back to cited text no. 3
Flood FB Spontaneous perforation of the umbilicus in Laennec’s cirrhosis with massive ascites. N Engl J Med 1961;264:72-4.  Back to cited text no. 4
DeLuca IJ, Grossman ME Flood syndrome. JAAD Case Rep 2015;1:5-6.  Back to cited text no. 5
Ginsburg BY, Sharma AN Spontaneous rupture of an umbilical hernia with evisceration. J Emerg Med 2006;30:155-7.  Back to cited text no. 6
Good DW, Royds JE, Smith MJ, Neary PC, Eguare E Umbilical hernia rupture with evisceration of omentum from massive ascites: A case report. J Med Case Rep 2011;5:170.  Back to cited text no. 7
Choo EK, McElroy S Spontaneous bowel evisceration in a patient with alcoholic cirrhosis and an umbilical hernia. J Emerg Med 2008;34:41-3.  Back to cited text no. 8
Chatzizacharias NA, Bradley JA, Harper S, Butler A, Jah A, Huguet E, et al. Successful surgical management of ruptured umbilical hernias in cirrhotic patients. World J Gastroenterol 2015;21:3109-13.  Back to cited text no. 9
Strainiene S, Peciulyte M, Strainys T, Stundiene I, Savlan I, Liakina V, et al. Management of Flood syndrome: What can we do better? World J Gastroenterol 2021;27:5297-305.  Back to cited text no. 10
Marsman HA, Heisterkamp J, Halm JA, Tilanus HW, Metselaar HJ, Kazemier G Management in patients with liver cirrhosis and an umbilical hernia. Surgery 2007;142:372-5.  Back to cited text no. 11


  [Figure 1], [Figure 2]


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