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A 68-year-old man with alcoholic cirrhosis, portal hypertension, ascites, and an umbilical hernia presented to the emergency department after an episode of coughing that was followed by a rush of fluid and fat from the umbilicus. The patient reported no abdominal pain. He had tense ascites but was otherwise asymptomatic before the episode and had no history of abdominal surgery. Physical examination revealed scleral icterus, spider angiomata, a distended abdomen with a fluid wave, and a 4-cm segment of omentum protruding from the umbilicus and draining ascitic fluid. In the operating room, strangulated omentum was found and resected, and the umbilical defect was repaired. Umbilical hernias are common in patients with ascites and result from elevated intraabdominal pressure in association with defects in the anterior abdominal wall. In rare cases, umbilical hernias may rupture. Factors precipitating rupture include local trauma, coughing, vomiting, or esophagoscopy. Complications of rupture include evisceration, confinement, or strangulation of bowel, as well as hypotension due to fluid shifts or peritonitis.
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