Figure it out fridays 

A 77-years-old gentleman presented to the Emergency Department with a sudden gush of approximately 3–4 L of fluid from his pre-existing umbilical hernia about 1 h prior to his presentation. He complained of a very tense and distended abdomen which was relieved with the spontaneous leakage of fluid from the umbilical hernia. He denied any prior trauma, abdominal pain, bleeding or fever. 

Past medical history: Child’s B alcoholic liver cirrhosis (MELD score = 18) complicated by esophageal varices, portal hypertension and diuretic intolerant recurrent ascites, requiring bi-weekly paracentesis for ascites drainage, and was due for his next paracentesis in 3 days. He had also previously declined transjugular intrahepatic portosystemic shunt (TIPS)

 

On examination:

Hemodynamically stable and afebrile without any signs of hepatic encephalopathy and asterixis

Abdomen: soft, non tender, mildly distended, splenomegaly 8 finger-breadths below the left subcostal margin. 

There was an erythematous umbilical hernia with a non-bleeding ulcer at the tip of the hernia from which straw-coloured ascitic fluid was actively draining. Bilateral lower limb pitting edema with scrotal and penile skin edema. 

 

Labs:

White blood cell count was 5.56 × 109/L (reference range 4–10 × 109/L)

Hb 9.2 g/dL (reference range 14–18 g/dL)

Platelet count of 164 × 109/L (reference range 140–440 × 109/L). 

Serum urea level of 20.8 mmol/L (reference range 2.7–6.9 mmol/L) 

Serum creatinine level of 185 µmol/L (reference range 54–101 µmol/L). 

Liver function test - normal apart from serum albumin level of 36 g/L (reference range 40–51 g/L).

 

What your diagnosis?

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A. Incarcerated umbilical hernia

B. Patent urachus

C. Flood syndrome

D. Umbilical granuloma

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