S5785 A Burst of Excitement: Case Presentation of Flood Syndrome

Introduction: Flood syndrome is the sudden drainage of ascitic fluid through an umbilical hernia. The term was aptly named by Dr. Frank B. Flood in the 1961 New England Journal of Medicine case series Spontaneous Perforation of the Umbilicus in Laennec's Cirrhosis with Massive Ascites. Patients with large volume ascites are at increased risk of umbilical hernia formation and inadequate ascitic fluid control puts patients at risk for drainage through the umbilical hernia. Patients typically present with cutaneous ulcerations or lesions at the site of the umbilicus prior to drainage. Typically preceded by an increase in intra-abdominal pressure (e.g., emesis, straining, coughing). Case Description/Methods: We present the case of a 57-year-old man with recently diagnosed alcohol cirrhosis complicated by recurrent ascites presenting with chief complaint of dyspnea and abdominal distention. Patient had required multiple paracenteses over the preceding months for recurrent ascites in the setting of diuretic non-adherence. Most recently had 3 liters of ascitic fluid removed approximately 2 weeks prior to presentation. Patient additionally noted recent viral illness with recurrent coughing. Labs were notable for a mild leukocytosis (WBC 12.8), thrombocytopenia (platelets 128), normal renal function, hyperbilirubinemia (total bilirubin 4.2). MELD 3.0 calculated to be 18 on arrival. Gastroenterology consulted on admission for hyperbilirubinemia and decompensated cirrhosis. On evaluation, found to have spontaneous drainage from umbilicus as pictured. Received albumin infusion and close monitoring in the intensive care unit. In total, 28 liters of ascitic fluid drained over the course of approximately 24 hours. General surgery consulted for umbilical hernia management, however deferred until hepatic disease managed. Interventional radiology consulted for transjugular intrahepatic portosystemic shunt evaluation; however, patient left against medical advice prior to definitive management. Outpatient hepatology follow-up pending at time of report. Discussion: Cirrhosis and its many complications are well detailed; however the coexistence of the 2 common entities of ascites and umbilical hernias leading to Flood syndrome are not well detailed. Many deleterious complications from Flood syndrome exist including bowel incarceration, hypotension, cellulitis, peritonitis, renal failure, and a mortality rate of 30%. Treatment algorithms are lacking and further follow-up of cases, such as the one presented here, can lead to assistance in understanding management of these patients.