Reviewing cullen's sign in acute pancreatitis

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136
Pictorial CME
A 56-year-old gentleman was referred to our hospital
with a diagnosis of alcohol-induced acute pancreatitis
with type 1 respiratory failure. On presentation, three
bluish-red discoloration marks were noted around the
umbilicus [Figure 1] but anks and thighs were free from any
skin changes. The marks were identied as Cullen’s sign due
to circumferential location around the umbilicus and absence
of itching, local tenderness, ulceration, heparin injection, or
other skin diseases. Serum amylase and lipase levels were
raised (more than 3 × of the upper limits) in the patients
and contrast-enhanced computed tomography confirmed
the diagnosis of acute necrotizing pancreatitis [Figure 2].
According to the revised Atlanta classication, the patient
was suering with severe acute pancreatitis as there was
persistent (>48 h) respiratory system failure. The patient
was managed in the intensive care unit with noninvasive
ventilation and supportive treatment, which led to a favorable
outcome.
dIscussIon
Cullen’s sign is the supercial ecchymosis and edema of
the periumbilical subcutaneous fatty tissue. It is named
after a gynecologist Thomas S. Cullen, who rst identied
this skin discoloration in a patient of ruptured extrauterine
pregnancy.[1] At present, the sign is elucidated in the context
of acute pancreatitis but has been documented in perforated
duodenal ulcer, postliver biopsy, ruptured abdominal aortic
or internal iliac artery aneurysm, postangiography or any
radiological intervention, pancreatic or abdominal trauma,
amebic liver abscess, metastatic esophageal cancer, ruptured
spleen and common bile duct, hepatocellular carcinoma,
and hepatic lymphoma.[2] The tracking of hemorrhagic uid
from the retroperitoneal region to the anterior abdominal
wall along with the falciform ligament causes this green/
yellow to purple skin bruising.[2] Grey Turner and Fox’s sign
are similar clinical signs, encountered in acute pancreatitis
and can occur simultaneously with Cullen’s sign. These
signs appear commonly on day 4 of hospitalization with a
female: male ratio of 3:1, and dierentials include abdominal
wall cellulitis, subcutaneous heparin administration, psoriasis,
and periumbilical endometriosis.[2-4] In a prospective study
including 770 patients with acute pancreatitis, Cullen’s sign
was observed in 1.17% and associated mortality was 37%
in this cohort.[4] Thus, Cullen’s sign is a rare but paramount
clinical mark of acute pancreatitis, which can delineate an
unfavorable prognosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient has given his
consent for his images and other clinical information to be
reported in the journal. The patient understands that name and
Address for correspondence: Dr. Gautam Jesrani,
Department of General Medicine, Government Medical College and
Hospital, Level‑4, D‑Block, Sector 32, Chandigarh ‑ 160 030, India.
E‑mail: jesranigautam@gmail.com
How to cite this article: Jesrani G, Gupta S, Kaur A, Cheema YS. Reviewing
cullen’s sign in acute pancreatitis. APIK J Int Med 2022;10:136-7.
Reviewing Cullen’s Sign in Acute Pancreatitis
Gautam Jesrani, Samiksha Gupta, Amandeep Kaur, Yuvraj Singh Cheema
Department of General Medicine, Government Medical College and Hospital, Chandigarh, India
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DOI:
10.4103/ajim.ajim_87_21
Received: 09.08.2021 Reviewed: 17.10.2021
Accepted: 18.10.2021 Published: 02.03.2022
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Figure 1: Bluish‑red discoloration around the umbilicus, suggestive of
Cullen’s sign
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Jesrani, et al.: Cullen’s sign in acute pancreatitis
APIK Journal of Internal Medicine ¦ Volume 10 ¦ Issue 2 ¦ April-June 2022 137
initials will not be published and due eorts will be made to
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Financial support and sponsorship
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Conflicts of interest
There are no conicts of interest.
RefeRences
1. Cullen TS. A new sign in ruptured extrauterine pregnancy. Am J Obstet
1918;78:457-60.
2. Rahbour G, Ullah MR, Yassin N, Thomas GP. Cullen’s sign-Case report
with a review of the literature. Int J Surg Case Rep 2012;3:143-6.
3. Dickson AP, Imrie CW. The incidence and prognosis of body wall
ecchymosis in acute pancreatitis. Surg Gynecol Obstet 1984;159:343-7.
4. Wright WF. Cullen sign and grey turner sign revisited. J Am Osteopath
Assoc 2016;116:398-401.
Figure 2: Contrast‑enhanced computed tomography of the abdomen
demonstrating bulky pancreas with heterogeneous enhancement and
peripancreatic fat stranding, suggestive of acute necrotizing pancreatitis
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