Flood Syndrome: A Life-Threatening Complication of Cirrhotic Ascites
Yes, Flood syndrome is a recognized medical condition, first described by Frank B. Flood in 1961, referring to the spontaneous rupture of an umbilical hernia in cirrhotic patients with ascites, resulting in uncontrolled leakage of ascitic fluid. 1, 2
Definition and Clinical Significance
Flood syndrome occurs when an umbilical hernia spontaneously ruptures in patients with end-stage liver disease and refractory ascites, causing ascitic fluid to leak uncontrollably from the opening. 1, 3
This condition represents a life-threatening complication with extremely high mortality and morbidity rates, particularly when emergency surgery is required. 4
Approximately 20% of cirrhotic patients with ascites develop umbilical herniation, making this a relatively common predisposing factor for the syndrome. 1
Warning Signs of Impending Rupture
Critical red flags that predict imminent hernia rupture include skin color changes overlying the hernia, ulceration of the hernial skin, or tissue necrosis—any of these findings warrant urgent surgical intervention. 2
The presence of a large, tense umbilical hernia in the setting of refractory ascites should raise immediate concern for potential rupture. 1, 2
Management Challenges and Controversies
The optimal management approach remains highly controversial, as these patients are typically poor surgical candidates due to end-stage liver disease, yet the ascitic leak will not resolve without surgical intervention. 3
Currently, no standardized treatment guidelines exist for Flood syndrome, forcing clinicians to rely on individual case reports and clinical judgment. 1, 3
The condition creates a clinical dilemma: conservative management fails to stop the leak and increases infection risk, while emergency surgery carries prohibitively high mortality in decompensated cirrhotic patients. 4, 3
Infection Risk and Complications
The continuous ascitic fluid leak creates a significant nidus for infection, with cirrhotic patients already having substantially elevated baseline infection risk due to multisystemic complications. 1, 3
Spontaneous bacterial peritonitis must be ruled out in any cirrhotic patient with ascites presenting with new symptoms, as it carries 20% mortality even with treatment. 5
Preventive Strategies
Elective umbilical hernia repair is increasingly recommended even for minimally symptomatic hernias in cirrhotic patients to avoid emergency surgery for rupture or strangulation. 4
Aggressive ascites management is mandatory to prevent hernia formation and rupture, including repeated large-volume paracentesis or transjugular intrahepatic portosystemic shunt (TIPS). 4
Without adequate ascites control, the risk of hernia recurrence after repair approaches 100%. 4
Surgical Considerations When Repair Is Necessary
For small defects, repair can be performed under local anesthesia to minimize surgical risk. 4
Laparoscopic repair offers advantages for large hernias by avoiding skin incisions (which prevents ascitic fluid leakage) and avoiding exposure of prosthetic mesh to potentially necrotic, infected tissue. 4
Necrotic skin tissue must be excised during repair, and prosthetic mesh can be used for large defects if ascites is confirmed sterile. 4
If liver transplantation is planned, hernia repair can be performed simultaneously unless the hernia is highly symptomatic, complicated, or the transplant waiting time is prolonged. 4