Hernia (2016) 20:531–533 DOI 10.1007/s10029-015-1421-2
CASE REPORT
Umbilical paracentesis for incarcerated umbilical hernia in patients with end-stage liver disease S. Alonso1 • M. Donat2 • L. Carrion1 • J. M. Rodriguez1 • L. Diego1 D. Acin1 • A. Serrano1 • E. Perez1 • F. Pereira1
•
Received: 26 March 2015 / Accepted: 14 August 2015 / Published online: 26 August 2015 Ó Springer-Verlag France 2015
Abstract Purpose Patients with cirrhosis and ascites are prone to abdominal wall complications largely predominate by umbilical hernia. Elective surgery is indicated in select patients but a high morbidity and mortality rate occurs if it is performed in emergency conditions. Methods We present a clinical case of a patient with advanced alcoholic liver disease who came to the emergency room for an acutely incarcerated umbilical hernia. Due to the high surgical risk, we had to discuss other treatment options. Results The use of umbilical paracentesis for incarcerated hernia reduction in cirrhotic patients with tense ascites is a safe and reproducible technique. Conclusions Umbilical paracentesis could be considered as an alternative to emergency surgery in these high-risk patients. Keywords Umbilical hernia Cirrhosis Complications Incarceration Ascites Paracentesis Abbreviations MELD Model for end-stage liver disease TIPS Paracentesis and transjugular intrahepatic portosystemic shunt UH Umbilical hernia
& S. Alonso [email protected] 1
General and Visceral Surgery Department, Fuenlabrada University Hospital, Madrid, Spain
2
General and Visceral Surgery Department, Infanta Leonor Hospital, Madrid, Spain
Background Patients with cirrhosis and ascites are prone to abdominal wall complications, mainly those related to umbilical hernias (UH). Elective surgery is indicated in selected patients. Emergency surgery in this setting is associated with high morbidity and mortality rates.
Case presentation A 54-year-old man with a history of advanced alcoholic liver disease (Child–Pugh class C) presented with lower abdominal pain and an acutely incarcerated umbilical hernia. A model for end-stage liver disease (MELD) score of 10 was calculated at hospital admission. The patient had a history of refractory ascites that had not stabilized over the past few months despite the use of high dose of diuretics. Examination revealed normal vital signs and a firm bulge at the umbilicus with skin erythema (Fig. 1). Abdominal inspection revealed a fluid-distended abdomen with tenderness on the lower quadrants. Under conscious sedation and analgesia, multiple attempts at hernia reduction were performed without success. Ultrasound imaging revealed ascitic fluid and small bowel within the umbilical hernia sac, with an aponeurotic defect of 3.7 cm (Figs. 2, 3). Using sterile ultrasound guidance, an umbilical paracentesis was performed and 600 mL of fluid was drained from the hernia sac (Fig. 4). Following the paracentesis, the hernia was successfully reduced (Figs. 5, 6). After 10 h of observation the patient was discharged. Six months after the procedure the patient was taken to the operating room for elective surgery. Intensive medical optimisation was performed before the surgery. An open hernia repair was carried out. No complications occurred during follow-up.
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Fig. 1 Incarcerated umbilical hernia with cutaneous erythema in patient with alcoholic cirrhosis and refractory ascites
Fig. 4 Umbilical paracentesis in patient with alcoholic cirrhosis and refractory ascites using sterile ultrasound guidance, draining 600 mL of fluid from the hernia sac
Fig. 2 Ultrasound visualization of ascitic fluid and small bowel within the umbilical hernia sac in patient with alcoholic cirrhosis and incarcerated umbilical hernia
Fig. 5 Successful reduction of the umbilical hernia in patient with alcoholic cirrhosis and refractory ascites
Fig. 3 Ultrasound visualization of an aponeurotic defect of 3.7 cm in patient with alcoholic cirrhosis and incarcerated umbilical hernia
Discussion Umbilical hernias occur in up to 20 % of patients with endstage liver disease [1], an incidence 10 times higher than the overall population [2, 3]. The incidence of UH in cirrhotic patients without ascites is similar to that of the
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Fig. 6 Ultrasound visualization of successful reduction of the umbilical hernia in patient with alcoholic cirrhosis and incarcerated umbilical hernia
Hernia (2016) 20:531–533
general population. On the other hand, the presence of ascites, and especially tense ascites, is associated with the existence of UH in 30–40 % of these patients [4]. The increased intra-abdominal pressure associated with ascites, along with the weakening of the abdominal wall fascia and musculature secondary to poor nutritional status, contributes to UH formation [5]. Patients with UH and liver cirrhosis have an increased probability of complications following hernia surgery, such as wound complications due to leakage of ascites, impending liver failure, or recurrence of the UH in the long term. Preoperative medical treatment of ascites is essential and is based on diuretics, paracentesis and sometimes even transjugular intrahepatic portosystemic shunt (TIPS), except when liver transplantation is indicated. Because of these risks, some surgeons often choose not to perform surgery for UH in cirrhotic patients [6]. On the other hand, because complications related to the UH are likely to occur during the lifetime of patients with cirrhosis, elective hernia repair is considered in many studies [7, 8], particularly in patients with well-controlled liver cirrhosis. Those series show that the morbidity in elective hernia repair is similar between cirrhotic and non-cirrhotic patients (approximately 15 %), while the risk is much higher when emergency surgery is needed, with a mortality rate seven times higher compared to elective surgery [9–11]. Some authors have reported a mortality rate as high as 30 % following emergency surgery [12]. Hansen et al. reported a total of 22840 patients with a diagnosis of cirrhosis; 201 underwent an emergency UH repair and 11 died within 30 days. In the control group (elective surgery), there was only one death. The adjusted OR for 30-day mortality was 3.9 % (IC 95 %, 0.7–31.2) [13]. Some groups have suggested abdominal paracentesis to attempt hernia reduction. Despite being a potential solution, incarceration of umbilical hernia during decompression of ascites has been reported in patients with cirrhosis [12, 14, 15]. Rapid removal of ascitic fluid after paracentesis may cause the reduction of the aponeurotic defect, which can lead to the incarceration of the UH. As far as we know, this is the second case reported in literature of the use of umbilical paracentesis for incarcerated hernia reduction in cirrhotic patients with tense ascites. We believe that this technique is safe and reproducible and that it could be considered as an alternative to emergency surgery in these high-risk patients.
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References 1. Belghiti J, Durand F (1997) Abdominal wall hernias in the setting of cirrhosis. Semin Liver Dis 17:219–226 2. Department of Health (1960) Education and Welfare: National health survey on hernias. Series B, Nj25. US Government Printing Office, Washington 3. Belghiti J, Rueff B, Fe´ke´te´ F (1983) Umbilical hernia in cirrhotic with ascites. Prevalence, course and management. Gastroentology 84:1363A (Abstract) 4. Silva FD, Andraus W, Pinheiro RS, Arantes-Junior RM, Lemes MP, Ducatti Lde S, D’albuquerque LA (2012) Abdominal and inguinal hernia in cirrhotic patients: what’s the best approach? Arq Bras Cir Dic 25:52–55 5. Baron HC (1960) Umbilical hernia secondary to cirrhosis of the liver. Complications of surgical correction. N Engl J Med 263:824–828 6. Choi SB, Hong KD, Lee JS, Han HJ, Kim WB, Song TJ, Suh SO, Kim YC, Choi SY (2011) Management of umbilical hernia complicated with liver cirrhosis: an advocate of early and elective herniorrhaphy. Dig Liver Dis 43:991–995 7. Ammar SA (2010) Management of complicated umbilical hernias in cirrhotic patients using permanent mesh: randomized clinical trial. Hernia 14:35–38 8. Eker HH, van Ramshorst GH, de Goede B, Tilanus HW, Metselaar HJ, de Man RA, Lange JF, Kazemier G (2011) A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites. Surgery 150:542–546 9. Carbonell AM, Wolfe LG, DeMaria EJ (2005) Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients. Hernia 9:353–357 10. Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA, Hawn MT (2008) Umbilical herniorrhapy in cirrhosis: improved outcomes with elective repair. J Gastrointest Surg 12:675–681 11. Marsman HA, Heisterkamp J, Halm JA, Tilanus HW, Metselaar HJ, Kazemier G (2007) Management in patients with liver cirrhosis and an umbilical hernia. Surgery 142:372–375 12. Triantos CK, Kehagias I, Nikolopoulou V, Burroughs AK (2010) Incarcerated umbilical hernia after large volume paracentesis for refractory ascites. J Gastrointestin Liver Dis 19:245 13. Hansen JB, Thulstrup AM, Vilstup H, Sørensen HT (2002) Danish nationwide cohort study of postoperative death in patients with liver cirrhosis undergoing hernia repair. Br J Surg 89:805–806 14. Trotter JF, Suhocki PV (1999) Incarceration of umbilical hernia following transjugular intrahepatic portosystemic shunt for the treatment of ascites. Liver Transpl Surg 5:209–210 15. Lemmer JH, Strodel WE, Eckhauser FE (1983) Umbilical hernia incarceration: a complication of medical therapy of ascites. Am J Gastroenterol 78:295–296
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CASE REPORT
Umbilical paracentesis for incarcerated umbilical hernia in patients with end-stage liver disease S. Alonso1 • M. Donat2 • L. Carrion1 • J. M. Rodriguez1 • L. Diego1 D. Acin1 • A. Serrano1 • E. Perez1 • F. Pereira1
•
Received: 26 March 2015 / Accepted: 14 August 2015 / Published online: 26 August 2015 Ó Springer-Verlag France 2015
Abstract Purpose Patients with cirrhosis and ascites are prone to abdominal wall complications largely predominate by umbilical hernia. Elective surgery is indicated in select patients but a high morbidity and mortality rate occurs if it is performed in emergency conditions. Methods We present a clinical case of a patient with advanced alcoholic liver disease who came to the emergency room for an acutely incarcerated umbilical hernia. Due to the high surgical risk, we had to discuss other treatment options. Results The use of umbilical paracentesis for incarcerated hernia reduction in cirrhotic patients with tense ascites is a safe and reproducible technique. Conclusions Umbilical paracentesis could be considered as an alternative to emergency surgery in these high-risk patients. Keywords Umbilical hernia Cirrhosis Complications Incarceration Ascites Paracentesis Abbreviations MELD Model for end-stage liver disease TIPS Paracentesis and transjugular intrahepatic portosystemic shunt UH Umbilical hernia
& S. Alonso [email protected] 1
General and Visceral Surgery Department, Fuenlabrada University Hospital, Madrid, Spain
2
General and Visceral Surgery Department, Infanta Leonor Hospital, Madrid, Spain
Background Patients with cirrhosis and ascites are prone to abdominal wall complications, mainly those related to umbilical hernias (UH). Elective surgery is indicated in selected patients. Emergency surgery in this setting is associated with high morbidity and mortality rates.
Case presentation A 54-year-old man with a history of advanced alcoholic liver disease (Child–Pugh class C) presented with lower abdominal pain and an acutely incarcerated umbilical hernia. A model for end-stage liver disease (MELD) score of 10 was calculated at hospital admission. The patient had a history of refractory ascites that had not stabilized over the past few months despite the use of high dose of diuretics. Examination revealed normal vital signs and a firm bulge at the umbilicus with skin erythema (Fig. 1). Abdominal inspection revealed a fluid-distended abdomen with tenderness on the lower quadrants. Under conscious sedation and analgesia, multiple attempts at hernia reduction were performed without success. Ultrasound imaging revealed ascitic fluid and small bowel within the umbilical hernia sac, with an aponeurotic defect of 3.7 cm (Figs. 2, 3). Using sterile ultrasound guidance, an umbilical paracentesis was performed and 600 mL of fluid was drained from the hernia sac (Fig. 4). Following the paracentesis, the hernia was successfully reduced (Figs. 5, 6). After 10 h of observation the patient was discharged. Six months after the procedure the patient was taken to the operating room for elective surgery. Intensive medical optimisation was performed before the surgery. An open hernia repair was carried out. No complications occurred during follow-up.
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Fig. 1 Incarcerated umbilical hernia with cutaneous erythema in patient with alcoholic cirrhosis and refractory ascites
Fig. 4 Umbilical paracentesis in patient with alcoholic cirrhosis and refractory ascites using sterile ultrasound guidance, draining 600 mL of fluid from the hernia sac
Fig. 2 Ultrasound visualization of ascitic fluid and small bowel within the umbilical hernia sac in patient with alcoholic cirrhosis and incarcerated umbilical hernia
Fig. 5 Successful reduction of the umbilical hernia in patient with alcoholic cirrhosis and refractory ascites
Fig. 3 Ultrasound visualization of an aponeurotic defect of 3.7 cm in patient with alcoholic cirrhosis and incarcerated umbilical hernia
Discussion Umbilical hernias occur in up to 20 % of patients with endstage liver disease [1], an incidence 10 times higher than the overall population [2, 3]. The incidence of UH in cirrhotic patients without ascites is similar to that of the
123
Fig. 6 Ultrasound visualization of successful reduction of the umbilical hernia in patient with alcoholic cirrhosis and incarcerated umbilical hernia
Hernia (2016) 20:531–533
general population. On the other hand, the presence of ascites, and especially tense ascites, is associated with the existence of UH in 30–40 % of these patients [4]. The increased intra-abdominal pressure associated with ascites, along with the weakening of the abdominal wall fascia and musculature secondary to poor nutritional status, contributes to UH formation [5]. Patients with UH and liver cirrhosis have an increased probability of complications following hernia surgery, such as wound complications due to leakage of ascites, impending liver failure, or recurrence of the UH in the long term. Preoperative medical treatment of ascites is essential and is based on diuretics, paracentesis and sometimes even transjugular intrahepatic portosystemic shunt (TIPS), except when liver transplantation is indicated. Because of these risks, some surgeons often choose not to perform surgery for UH in cirrhotic patients [6]. On the other hand, because complications related to the UH are likely to occur during the lifetime of patients with cirrhosis, elective hernia repair is considered in many studies [7, 8], particularly in patients with well-controlled liver cirrhosis. Those series show that the morbidity in elective hernia repair is similar between cirrhotic and non-cirrhotic patients (approximately 15 %), while the risk is much higher when emergency surgery is needed, with a mortality rate seven times higher compared to elective surgery [9–11]. Some authors have reported a mortality rate as high as 30 % following emergency surgery [12]. Hansen et al. reported a total of 22840 patients with a diagnosis of cirrhosis; 201 underwent an emergency UH repair and 11 died within 30 days. In the control group (elective surgery), there was only one death. The adjusted OR for 30-day mortality was 3.9 % (IC 95 %, 0.7–31.2) [13]. Some groups have suggested abdominal paracentesis to attempt hernia reduction. Despite being a potential solution, incarceration of umbilical hernia during decompression of ascites has been reported in patients with cirrhosis [12, 14, 15]. Rapid removal of ascitic fluid after paracentesis may cause the reduction of the aponeurotic defect, which can lead to the incarceration of the UH. As far as we know, this is the second case reported in literature of the use of umbilical paracentesis for incarcerated hernia reduction in cirrhotic patients with tense ascites. We believe that this technique is safe and reproducible and that it could be considered as an alternative to emergency surgery in these high-risk patients.
533
References 1. Belghiti J, Durand F (1997) Abdominal wall hernias in the setting of cirrhosis. Semin Liver Dis 17:219–226 2. Department of Health (1960) Education and Welfare: National health survey on hernias. Series B, Nj25. US Government Printing Office, Washington 3. Belghiti J, Rueff B, Fe´ke´te´ F (1983) Umbilical hernia in cirrhotic with ascites. Prevalence, course and management. Gastroentology 84:1363A (Abstract) 4. Silva FD, Andraus W, Pinheiro RS, Arantes-Junior RM, Lemes MP, Ducatti Lde S, D’albuquerque LA (2012) Abdominal and inguinal hernia in cirrhotic patients: what’s the best approach? Arq Bras Cir Dic 25:52–55 5. Baron HC (1960) Umbilical hernia secondary to cirrhosis of the liver. Complications of surgical correction. N Engl J Med 263:824–828 6. Choi SB, Hong KD, Lee JS, Han HJ, Kim WB, Song TJ, Suh SO, Kim YC, Choi SY (2011) Management of umbilical hernia complicated with liver cirrhosis: an advocate of early and elective herniorrhaphy. Dig Liver Dis 43:991–995 7. Ammar SA (2010) Management of complicated umbilical hernias in cirrhotic patients using permanent mesh: randomized clinical trial. Hernia 14:35–38 8. Eker HH, van Ramshorst GH, de Goede B, Tilanus HW, Metselaar HJ, de Man RA, Lange JF, Kazemier G (2011) A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites. Surgery 150:542–546 9. Carbonell AM, Wolfe LG, DeMaria EJ (2005) Poor outcomes in cirrhosis-associated hernia repair: a nationwide cohort study of 32,033 patients. Hernia 9:353–357 10. Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA, Hawn MT (2008) Umbilical herniorrhapy in cirrhosis: improved outcomes with elective repair. J Gastrointest Surg 12:675–681 11. Marsman HA, Heisterkamp J, Halm JA, Tilanus HW, Metselaar HJ, Kazemier G (2007) Management in patients with liver cirrhosis and an umbilical hernia. Surgery 142:372–375 12. Triantos CK, Kehagias I, Nikolopoulou V, Burroughs AK (2010) Incarcerated umbilical hernia after large volume paracentesis for refractory ascites. J Gastrointestin Liver Dis 19:245 13. Hansen JB, Thulstrup AM, Vilstup H, Sørensen HT (2002) Danish nationwide cohort study of postoperative death in patients with liver cirrhosis undergoing hernia repair. Br J Surg 89:805–806 14. Trotter JF, Suhocki PV (1999) Incarceration of umbilical hernia following transjugular intrahepatic portosystemic shunt for the treatment of ascites. Liver Transpl Surg 5:209–210 15. Lemmer JH, Strodel WE, Eckhauser FE (1983) Umbilical hernia incarceration: a complication of medical therapy of ascites. Am J Gastroenterol 78:295–296
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