Cullen’s and Grey Turner’s Signs in Acute Pancreatitis

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A 63-year-old man with no history of alcohol abuse presented with sudden, severe epigastric pain. The serum lipase level was elevated (1380 U per liter; normal range, 22 to 51 U per liter), a finding consistent with acute pancreatitis. Abdominal ultrasonography revealed cholelithiasis without evidence of choledocholithiasis. The patient received supportive care with fluid hydration, pain medication, and bowel rest. His condition deteriorated, and he was transferred to the intensive care unit 2 days after hospital admission. Physical examination at the time of the transfer revealed jaundice, with an elevated total serum bilirubin level (4.2 mg per deciliter [71 μmol per liter]; normal range, 0.06 to 0.99 mg per deciliter [1 to 17 μmol per liter]) and abdominal distention with periumbilical ecchymosis (Cullen’s sign) (Panel A) and ecchymosis of the flank (Grey Turner’s sign) (Panel B). These discolorations are a result of liberated pancreatic enzymes causing the diffusion of fat necrosis and inflammation with retroperitoneal or intraabdominal bleeding; the diffusion occurs from the retroperitoneum to the umbilicus through the round ligament for Cullen’s sign and from the retroperitoneum to the subcutaneous tissues of the flanks for Grey Turner’s sign. These signs, although not specific, are associated with severe acute pancreatitis and high mortality. Computed tomography confirmed the presence of necrotizing pancreatitis with several acute peripancreatic fluid collections (Balthazar grade E) and gallstones in the gallbladder, with no choledocholithiasis. Multiple-organ-system failure developed, and the patient eventually died from complications of pancreatitis despite supportive care.

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