Spontaneous rupture of umbilical hernia in refractory ascites leading to improvement in clinical condition

Refractory ascites in patients with end-stage liver disease is a difficult problem to manage. Large-volume paracentesis is often used for the control of the ascites and its associated symptoms, such as respiratory distress. Such an approach is not ideal in that it can cause systemic volume and electrolyte abnormalities, as well as precipitate hepatorenal syndrome. We report a case of intermittent spontaneous paracentesis through a ruptured umbilical hernia with improvement in clinical condition. The patient is a 44- year-old male with Child's Class C cirrhosis, secondary to chronic hepatitis B and C as well as alcohol abuse. He had a number of hospitalizations for tense ascites, and encephalopathy requiring ICU monitoring on two occasions in the past. The patient was hospitalized with tense ascites, and was noted to have a 4x4x6 cm umbilical hernia. The tension in the hernia was used as a marker for intra-abdominal pressure and this, along with respiratory distress, was used as a guide for timing of therapeutic paracentesis. Over the first three weeks of the hospital stay, approximately 12 liters were removed over three occasions. The patient required transfer to the ICU twice for encephalopathy that was temporally related to her paracenteses. Then, the hernia ruptured and a 0.5 cm hole formed in the skin. Ascitic fluid drained rapidly at first, and then the rate decreased. Surgical repair was not felt to be feasible due to poor general condition and persistent ascites which would make healing unlikely. A colostomy bag was placed over the hernia rupture site, and it was noted to drain a variable amount daily, presumably based on the intra-abdominal pressure. His condition improved dramatically, and he had no further episodes of encephalopathy or necessity for ICU transfer, and was able to be discharged within one week of hernia rupture. He did have one episode of peritonitis the day after the rupture, which was easily treated with antibiotics and has not recurred at the time of last follow-up. Conclusions: 1) In this patient, daily small-volume paracentesis was better tolerated than intermittent large-volume paracentesis; 2) This case may provide insight into possible new therapeutic modalities that mimic this spontaneously occurring pressure-regulated valve.