The American Journal of Medicine
Volume 122, Issue 11 , Page e17, November 2009

The Reply

  • Markus Bosmann, MD

      Affiliations

    • First Department of Medicine, University of Mainz, Germany, Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan
    • ,
  • Oliver Schreiner, MD

      Affiliations

    • First Department of Medicine, University of Mainz, Germany
    • ,
  • Peter R. Galle, MD

      Affiliations

    • First Department of Medicine, University of Mainz, Germany

Article Outline

 

It has long been appreciated that Cullen's and Grey Turner's signs are both not specific for acute pancreatitis but can occur in a myriad of pathologic processes all involving intra- and retroabdominal hemorrhage. Indeed, reports in the literature also comprise cases of metastatic thyroid cancer,1 esophageal cancer,2 intra-abdominal non-Hodgkin's lymphoma,3 and amoebic liver abscess4 that are rarely associated with the occurrence of these body wall ecchymoses. This list also encompasses a variety of other clinical conditions. However, many cases with Cullen's or Grey Turner's signs are attributable to acute pancreatitis. Hemorrhage during acute pancreatitis in combination with the release of pancreatic enzymes seems to facilitate the spread of blood via anatomic fasciae becoming visible on the abdominal wall.

Cullen's and Grey Turner's signs were first described at a time when physicians had to base a diagnosis mainly on patient history, physical examination, and clinical experience rather than an arsenal of modern laboratory studies and imaging techniques. Currently, however, Cullen's and Grey Turner's signs have little relevance for early diagnosis of acute pancreatitis. Noteworthy, these signs typically only appear several days after the onset of pancreatitis.

Why should physicians then still apply these signs to clinical practice? First, Cullen's and Grey Turner's signs to some degree indicate the severity of pancreatitis. Dickson and Imrie5 have studied 770 patients with acute pancreatitis and found that in the 23 patients (3%) who developed body wall ecchymoses, there was a higher incidence of complications, particularly pseudocyst formation. The mortality rate among that subgroup of patients was 37%. Second, nursing staff, patients, and relatives can become worried when such stigmata become visible on the abdominal wall. Physicians also have a mandate to explain the nature of these medical symptoms to their patients. Indeed, patients often undergo a sudden degree of relief when they think their doctor recognizes their symptoms and even can specifically name them, for example, as Cullen's and Grey Turner's signs.

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References 

  1. Marinella MA. Cullen's sign associated with metastatic thyroid cancer. [see comment] N Engl J Med. 1999;340:149–150
  2. Marinella MA, Baumann M. Cullen's sign associated with metastatic esophageal carcinoma. J Hosp Med. 2008;3:277–278(Online)
  3. Silvestre JF, Jover R, Betlloch I, et al. Cullen's sign secondary to intra-abdominal non-Hodgkin's lymphoma. Am J Gastroenterol. 1996;91:1040–1041
  4. Misra A, Agrahari D, Gupta R. Cullen's sign in amoebic liver abscess. Postgrad Med J. 2002;78:427–428
  5. Dickson AP, Imrie CW. The incidence and prognosis of body wall ecchymosis in acute pancreatitis. Surg Gynecol Obstet. 1984;159:343–347

PII: S0002-9343(09)00683-4

doi:10.1016/j.amjmed.2009.08.002

Refers to article:

  • Regarding the Coexistence of Cullen's and Grey Turner's Signs in Acute Pancreatitis

    Fuad Jan, Suhail Allaqaband, Hina Mahboob
    The American Journal of Medicine November 2009 (Vol. 122, Issue 11, Page e15)

The American Journal of Medicine
Volume 122, Issue 11 , Page e17, November 2009

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