An 81-year-old Caucasian man, with a background history of alcoholic liver disease, presented acutely via our emergency department, with an erythematous umbilical hernia and clear, yellow discharge from the umbilicus. Clinical examination showed signs of decompensated liver disease, including asterixis, spider naevi, a distended abdomen with shifting dullness, fluid thrill and an erythematous umbilical hernia. On straining for stool, after initial clinical assessment, our patient noted a gush of fluid and evisceration of omentum from the umbilical hernia. An urgent laparotomy was performed, using povidone-iodine solution for skin preparation via a midline incision, with excision of the umbilicus and devitalized omentum. Of note, there was evidence of recanalization of the umbilical vein. A full examination of the abdominal viscera was performed, and samples of ascitic fluid sent for cytological, biochemical and microbiological analysis. The liver was noted to be nodular, shrunken and sclerotic with generalized fibrinous exudate lining the coelomic cavity. His post-operative α-fetoprotein was 798 IU/mL. The abdominal fascial edges were re-apposed with interrupted 1/0 polypropylene sutures, with clips to the skin. The ascitic fluid serum-ascites albumin gradient was >1.1 g/dL, and showed increased ascitic protein level (>2.5 g/dl). Cytology was negative for malignant cells.