S2422 Flood Syndrome: A Systematic Review of Reported Cases and Management Outcomes

Introduction: Flood syndrome is a rare but life-threatening condition that occurs in patients with end-stage liver disease complicated by umbilical hernia, especially those with large-volume ascites. Umbilical hernias are seen in up to 20% of cirrhotic patients with ascites. In some patients, spontaneous rupture of an umbilical hernia leads to a sudden and significant ascitic fluid leakage. Managing Flood syndrome remains a challenge, as there is no clear or standardized treatment. Some reports suggest that elective hernia repair in cirrhotic patients lowers the 30-day mortality rate, around 1.2%, compared to emergency surgery, which may have a rate as high as 12.2%. Methods: For this systematic review, we searched PubMed, Scopus, Web of Science, and Embase until April 2025 to identify relevant case reports or case series on flood syndrome. We found a total of 60 relevant publications. From these, we collected and reviewed information on patient age, symptoms, the method of diagnosis, treatment approaches, and patient outcomes. Results: A total of 60 studies were included, representing approximately 142 cases of Flood syndrome. The mean age of the patients was 53.82 ± 12.10 years, with a slight man predominance (65.8%). Seventy-six patients (52%) presented with spontaneous rupture of an umbilical hernia accompanied by ascitic fluid leak; the remaining presented with abdominal swelling with skin ulceration. All patients received medical management, Additionally, 21 patients underwent paracentesis. Eighty-four patients (57.53%) underwent surgical repair of the hernial defect, the remaining patients were managed with minimally invasive techniques. There were 11 cases (7.5%) of recurrent umbilical hernia reported after management. Mortality was noted in 20 patients (13.7%), 14 of whom (9.6%) had undergone surgical repair. Conclusion: Flood syndrome is associated with significant morbidity and mortality, especially in patients who underwent emergency surgery. Elective hernia repair in patients with stable liver function and controlled ascites has, however, shown lower death rates, particularly when performed laparoscopically. These findings support the need to reconsider current management and examine whether earlier elective intervention could prevent rupture and improve mortality rates. Further research is necessary to create clear guidelines on when surgical repair is appropriate and which patients are suitable to prevent this life-threatening complication.