Management of Flood syndrome: What can we do better?

Table 1 Risk for herniation and possible hernia rupture establishment and prevention of umbilical hernia rupture/reoccurrence

Risk establishment	Prevention
Questions to ask
(1) Ascites control: (a) Changes in the abdomen volume; (b) Fluid balance; (c) Weight; (d) Use of prescribed treatment; (2) Nutrition (any signs of malnutrition?); (3) Alcohol intake; (4) Surgeries in the abdomen; (5) Pre-existing hernias; (6) Employment (heavy lifting activities); (7) Comorbidities; (8) Constipation; (9) Medicaments used; and (10) Changes in the abdomen, umbilical area visual appearance	(1) Education; (2) Risk establishment; and (3) Risk management: (a) Lifestyle modification; (b) Management of the underlying liver disease; (c) Management of ascites; (d) Doctor-patient communication; and (e) Communication between medical specialists
	Patients with UH
	(1) All the above; (2) Avoid heavy lifting, rapid movement; (3)Abdominal surgeon consult; and (4) Elective surgery in stable patients

UH: Umbilical hernia.

Table 2 Summary of the guidelines on the management of ascites

	Treatment
Main measures	Moderate restriction of sodium intake, 80–120 mmoL/d (4.6-6.9 g of salt/d)
	Adequate nutrition: Protein-rich diet (2000 kcal/d, protein–40-50 g/d), vitamin therapy
	Correction of electrolyte imbalance
	Adequate fluid intake: No restriction needed in patients with normal serum sodium concentration; in hyponatremic patients (< 130 mmoL/L), restrict fluid intake to 1.0-1.5 L/d
	Daily track of weight (or measure fluid intake and diuresis)
	The maximum recommended weight loss during diuretic therapy: (1) 0.5 kg/d in patients without edema; and (2) 1 kg/d in patients with edema
Mild and moderate ascites (grade Iº-IIº)	Aldosterone antagonists: Spironolactone 50-100 mg/d (maximum of 400 mg/d) ± loop diuretics: Furosemide 20-40 mg/d (maximum of 160 mg/d)
	Torasemide (10-40 mg/d) if no response to furosemide
	Distal diuretics: Amiloride 5-20 mg/d; triamterene 100 mg 2 k./d. (if aldosterone antagonists are not tolerated)
	Combined dosage of diuretics: Spironolactone 50-100-200-300-400 mg/d (in 100 mg steps) + furosemide 20-40-80-120-160 mg/d (in 40 mg steps) (or adequate doses of other diuretics)
Large ascites (grade IIIº)	LVP
	Albumin infusion (8 g/L of ascitic fluid removed)
	Minimal effective dose of diuretics to prevent the re-accumulation of ascites after LVP
Refractory ascites	Repeated partial or large volume paracentesis + albumin infusion
	Withdrawn diuretics
	Transjugular intrahepatic portosystemic shunt
	Alternative drugs: (1) α1 adrenergic agonists–midodrine 7.5 mg 3 times/d; (2) Vasopressin analog–terlipressin 1-2 mg/d intravenous; and (3) α2 adrenergic agonists–clonidine
	Alfapump system
	Liver transplantation

LVP: Large volume paracentesis.