Flood Syndrome Complicated by Omental Evisceration in Budd-Chiari Syndrome-Related Ascites: A Case Report

Abstract: Introduction and Importance: Umbilical hernia is common in patients with chronic ascites, but spontaneous rupture with evisceration is rare and potentially fatal. Most published reports concern cirrhosis; occurrence in Budd-Chiari syndrome is less frequently documented. This report describes omental evisceration after a short prodrome of umbilical swelling and ascitic leakage in a young woman with Budd-Chiari syndrome. Presentation of Case: A 27-year-old woman with Budd-Chiari syndrome and chronic ascites, treated with acenocoumarol, spironolactone and furosemide, was transferred for omental evisceration through an umbilical defect. One week earlier, she had developed an umbilical swelling followed by clear fluid leakage after scratching the overlying skin. She remained afebrile and haemodynamically stable, with preserved bowel transit and no peritoneal irritation. The abdomen was distended and a viable omental segment protruded through a 2-cm cutaneous defect. Laboratory testing showed severe hyponatraemia (118 mmol/L), thrombocytopenia (90 × 10^9/L), a prothrombin time of 40% and an international normalised ratio of 1.89. After critical-care review and correction of hyponatraemia, emergency midline laparotomy confirmed viable eviscerated omentum. Omentectomy and primary umbilical hernia repair with four interrupted X sutures of absorbable suture material size 1 were performed. The immediate postoperative course was reported as uncomplicated. Clinical Discussion: Refractory ascites increases intra-abdominal pressure, enlarges the umbilical ring and compromises the overlying skin. Ulceration or ascitic leakage may precede rupture. Evisceration requires urgent operative management after focused resuscitation. Primary suture repair avoids implantation of prosthetic material in an emergency field, although recurrence remains closely linked to postoperative ascites control. Conclusion: Umbilical leakage in a patient with ascites should be treated as a warning sign of impending rupture. Exposed omentum or bowel requires protection, physiological optimisation and urgent surgery. Long-term success depends on coordinated control of ascites and the underlying hepatic venous outflow obstruction.