P1856 - Rare but Deadly: A Case of Nearly Missed Flood Syndrome

Soumya Ramireddy, BS¹, David J. Westrich, MD², Kamran Qureshi, MD^1
1St. Louis University School of Medicine, St. Louis, MO; ²St. Louis University Hospital, St. Louis, MO

Introduction: Flood syndrome describes a spontaneous umbilical hernia rupture with release of ascitic fluid and development of peritonitis and sepsis. Up to 50% of patients with cirrhosis have ascites, and 20% have an umbilical hernia. Therefore, while the syndrome is rare, a significant proportion of patients with cirrhosis are at risk of developing it. It has a mortality rate of 30-50% and requires urgent diagnosis and surgical evaluation. Here, we present a case of nearly missed flood syndrome.

Case Description/Methods: A 67-year-old man with alcohol-related cirrhosis presented to a local emergency room for fluid leaking from an umbilical hernia. One day prior, he had had a large-volume paracentesis (LVP) on his left flank. Vitals were within normal limits. Exam showed an umbilical hernia with ulceration and leaking ascitic fluid. It was closed with a suture, and he was discharged. The next day, he returned with severe abdominal pain and was transferred to our tertiary care center. On arrival, he was afebrile but tachycardic and hypotensive. On exam, bowel sounds were hypoactive, the abdomen was diffusely tender with guarding, and his umbilical hernia was draining ascitic fluid. Labs were notable for leukocytosis with a left shift, lactic acidosis, new hyponatremia, and acute renal failure. Flood syndrome was diagnosed, and he was started on antibiotics. Cultures grew methicillin-susceptible Staphylococcus aureus from his ascitic fluid and blood. His course was complicated by septic shock, hepatorenal syndrome, and ileus. He underwent urgent umbilical hernia repair with transplant surgery. He ultimately survived and was discharged home two weeks later. He has since been sober and is listed for a liver transplant.

Discussion: Flood syndrome is due to the chronic breakdown of peritoneum and skin that occurs in an umbilical hernia under constant pressure from ascites, in the setting of poor nutrition and healing associated with cirrhosis. While it may seem counterintuitive that the rupture occurred after LVP, any sudden change in intra-abdominal pressure increases rupture risk. As seen in this case, ulceration on the hernia is also associated with increased rupture risk. The precipitous decline that this patient experienced early in his course demonstrates the value of identifying patients at risk for flood syndrome, early recognition of its presentation, and urgent multidisciplinary treatment. Likewise, his recovery shows that, while potentially fatal, flood syndrome can be managed with a favorable outcome.


Disclosures:


Soumya Ramireddy, BS¹, David J. Westrich, MD², Kamran Qureshi, MD¹. P1856 - Rare but Deadly: A Case of Nearly Missed Flood Syndrome, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.