Correspondence

Cullen's and Turner's Signs

N Engl J Med 2006; 354:979-980March 2, 2006

Article

To the Editor:

Cullen's and Turner's signs have long been known to be associated with retroperitoneal bleeding, as illustrated in the images presented by Mookadam and Cikes (Sept. 29 issue).1 However, the mechanisms underlying the appearance of these signs have only recently been clarified with a better understanding of the embryonic development of the various layers of the retroperitoneum.2,3 Cullen's sign arises from the spread of retroperitoneal blood into the falciform ligament and subsequently to subcutaneous umbilical tissues through the connective tissue covering of the round ligament. In contrast, Turner's sign is produced by hemorrhagic fluid spreading from the posterior pararenal space to the lateral edge of the quadratus lumborum muscle and thereafter to the subcutaneous tissues by means of a defect in the fascia of the flank.

Afshin Farzaneh-Far, M.R.C.P., Ph.D.
Brigham and Women's Hospital, Boston, MA 02115

3 References

1. 1

   Mookadam F, Cikes M. Cullen's and Turner's signs. N Engl J Med 2005;353:1386-1386
   Full Text | Web of Science | Medline

2. 2

   Bem J, Bradley EL III. Subcutaneous manifestations of severe acute pancreatitis. Pancreas 1998;16:551-555
   CrossRef | Web of Science | Medline

3. 3

   Gore RM, Balfe DM, Aizenstein RI, Silverman PM. The great escape: interfascial decompression planes of the retroperitoneum. AJR Am J Roentgenol 2000;175:363-370
   Web of Science | Medline

To the Editor:

The patient presented by Mookadam and Cikes demonstrates clear Cullen's and Turner's signs. Additionally, however, the upper lateral aspect of the patient's thighs shows an ecchymosis having a sharply demarcated superior border paralleling but inferior to the inguinal ligament. This is Fox's sign of retroperitoneal hemorrhage.1,2 Fox hypothesized that free blood can track extraperitoneally along the fascia of the psoas and iliac muscles, becoming subcutaneous in the upper thigh. He further hypothesized that the sharp superior border resulted from blockage of further blood movement at the junction of Scarpa's fascia with the fascia lata.1 The blue scrotum sign of Bryant3 is a fourth eponymous sign of retroperitoneal hemorrhage.

John G. Sotos, M.D.
Apneos, Belmont, CA 94002
ecchymosis2005@zebras.com

3 References

1. 1

   Fox JA. A diagnostic sign of extraperitoneal hemorrhage. Br J Surg 1966;53:193-195
   CrossRef | Web of Science | Medline

2. 2

   Qvist G. Surgical diagnosis. London: HK Lewis, 1977:283.
   

3. 3

   Ratzan RM, Donaldson MC, Foster JH, Walzak MP. The blue scrotum sign of Bryant: a diagnostic clue to ruptured abdominal aortic aneurysm. J Emerg Med 1987;5:323-329
   CrossRef | Medline

Author/Editor Response

Our reason for submitting these images was the rarity of having a patient with all three signs. We agree with Dr. Farzaneh-Far regarding the mechanisms underlying the appearance of Cullen's and Turner's signs, which we were unable to elaborate on because of space limitations. Recently, the anatomical pathways of the extravasated pancreatic enzymes leading to these ecchymoses, as well as the effects of the enzymes on the ecchymoses, were demonstrated by multiplanar reformation images obtained by helical computed tomography in a patient with severe acute pancreatitis.1

We would like to thank Dr. Sotos for pointing out the third (Fox's) and fourth (Bryant's) signs of retroperitoneal hemorrhage. The images clearly show Fox's sign, and a review of our own unpublished images suggests the presence of Bryant's sign. Our original submission to the Journal pointed out Fox's but not Bryant's sign, but this text was omitted owing to space constraints. The expert clinical observations of Drs. Sotos and Farzaneh-Far have completed and enhanced our text by the inclusion of Bryant's sign of scrotal discoloration. We use the term “discoloration” to describe the ecchymosis or its evolution over time in the umbilical area, loin, and inguinal areas.

Farouk Mookadam, M.D.
Mayo Clinic, Rochester, MN 55905
mookadam.farouk@mayo.edu

Maja Cikes, M.D.
University Hospital Center, 10000 Zagreb, Croatia

1 References

1. 1

   Sugimoto M, Takada T, Yasuda H, et al. MPR-hCT imaging of the pancreatic fluid pathway to Grey-Turner's and Cullen's sign in acute pancreatitis. Hepatogastroenterology 2005;52:1613-1616
   Web of Science | Medline