A Leak From Within: A Case Report on Flood Syndrome

Flood syndrome is a very rare complication that can be found in patients with end-stage liver cirrhosis with concurrent ventral hernias. If the hernia ruptures, ascites can begin to leak uncontrollably from the opening which can become a nidus for infection if left untreated. This scenario is known as Flood syndrome, which was first described by Frank Flood in 1961. Flood syndrome is very difficult to manage for physicians as these patients are poor candidates for surgery but the ascitic leak will continue without surgical intervention. Currently, there is no standard of care for Flood syndrome. A 66-year-old Caucasian male with a past medical history of NASH cirrhosis, type 2 diabetes, COPD, umbilical hernia, and CAD presented with a sudden burst of ascitic fluid after his umbilical hernia spontaneously ruptured with no inciting event or trauma. The ascites had been progressively getting worse since the patient underwent his last therapeutic paracentesis (two weeks prior to admission) which drained 12.5 liters. Empiric antibiotics were started due to increased risk of bacterial peritonitis. IV albumin was also given to maintain oncotic pressure and prevent "third-spacing". Of note, patient was not given any additional fluids due to his hyponatremic state. General surgery and hepatology was consulted and recommended a binder with gauze changes as necessary since patient was a very poor candidate for surgery with a MELD score of 26. MELD scores are an excellent predictor of morbidity and mortality for patients with end-stage liver disease. After the patient was admitted, an attempt was made to control the ascitic leak via a pursestring suture. The patient's abdomen was prepped and draped in the standard sterile fashion. Lidocaine was used to anesthetize the skin of his umbilicus. There was about 2 cm diameter of gangrenous area with a hole leaking ascites in the middle. A pursestring suture of 3-0 chromic gut absorbable suture was placed around the defect to tightly close the wound. The patient tolerated the procedure well. There was no leak detected with the Valsalva maneuver after the placement of the pursestring. Two days later, however, the pursestring failed and the ascites began to leak again around the pursestring through the previously existing defect. Six days later, the patient was transferred to palliative care and later discharged despite the continued ascitic leak since he was not a transplant candidate or a candidate for surgery per surgery and hepatology. Patient was advised to continue weekly therapeutic paracenteses to manage the ascitic leak. The patient presented again twelve days later due to abdominal pain from a loop of small bowel being incarcerated and strangulated at the umbilical hernia. Despite being a poor surgical candidate, the patient and his wife agreed to undergo an umbilical hernia repair with mesh and small bowel resection due to the emergent nature of his case. The surgery was performed successfully and the patient was discharged from the hospital eleven days later in stable condition.