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| PICTORIAL CME |
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| Year : 2022 | Volume
: 10
| Issue : 2 | Page : 136-137 |
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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
| Date of Submission | 09-Aug-2021 |
| Date of Decision | 17-Oct-2021 |
| Date of Acceptance | 18-Oct-2021 |
| Date of Web Publication | 02-Mar-2022 |
Correspondence Address:
Dr. Gautam Jesrani
Department of General Medicine, Government Medical College and Hospital, Level-4, D-Block, Sector 32, Chandigarh - 160 030
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ajim.ajim_87_21
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 |
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 flanks and thighs were free from any skin changes. The marks were identified 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 classification, the patient was suffering 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. | Figure 1: Bluish-red discoloration around the umbilicus, suggestive of Cullen's sign
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 | 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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| Discussion | |  |
Cullen's sign is the superficial ecchymosis and edema of the periumbilical subcutaneous fatty tissue. It is named after a gynecologist Thomas S. Cullen, who first identified 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 fluid 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 differentials include abdominal wall cellulitis, subcutaneous heparin administration, psoriasis, and periumbilical endometriosis.[2],[3],[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 initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts 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 1], [Figure 2]
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