Cullen sign

Description

Cullen sign: superficial oedema with bruising in the subcutaneous fatty tissue around the peri-umbilical region. Originally described in association with ectopic pregnancy.

Cullen sign has been described in myriad clinical scenarios including acute pancreatitis; rectus sheath haematoma; massive ovarian enlargement; amoebic liver abscess; splenic rupture; perforated duodenal ulcer; metastatic thyroid cancer; intra-abdominal non-Hodgkin’s lymphoma and as a complication of anticoagulation.


History

Original publication: (n=1)

1918Thomas Stephen Cullen first described a bluish black discoloration of the periumbilical skin in a female patient with a ruptured extrauterine pregnancy with ‘no history of injury‘ – Cullen sign

He concluded that the umbilical appearance was due to intra-abdominal haemorrhage secondary to an ectopic pregnancy. He originally described the finding at the 43rd annual meeting of the Transactions of the American gynecological society, Pennsylvania May 16-18 1918

The patient, a woman, thirty-eight years of age, suddenly developed abdominal pain and distention. Dr. Cullen saw her three weeks later. The umbilical region was bluish black, although she gave no history of injury. Vaginal examination yielded nothing on account of the abdominal distention. Under ether, however, a mass 8 X 6 cm. was clearly felt to the right of the uterus. Dr. Cullen at once diagnosed extrauterine pregnancy, although the patient had missed no period and there was no uterine bleeding. On opening the abdomen he found a right-sided extrauterine pregnancy and about one and a half quarts of free blood in the abdomen. He referred to a case reported by Ransohoff where a man, fifty-three years of age, had obscure abdominal symptoms. jaundice of the umbilical region was soon noted and at operation rupture of the common duct was found and there was much free bile in the abdomen. judging from analogy the speaker naturally concluded that the bluish-black appearance of the umbilicus was due to intraabdominal hemorrhage, and the presence of the nodule to the side of the uterus clinched the diagnosis of extrauterine pregnancy.

Cullen TS 1918

Cullen sign has been described in myriad clinical scenarios

CauseReference
Retroperitoneal necrotizing fasciitisPryor et al 2001
Strangulated umbilical herniaOrient JM, Sapira JD 2005
Strangulation of ileum with hemorrhageOrient JM, Sapira JD 2005
Renal sarcoma metastatic to the peritoneumOrient JM, Sapira JD 2005
Ovarian cyst hemorrhageOrient JM, Sapira JD 2005
Hypothyroid myopathyOrient JM, Sapira JD 2005
Hepatocellular carcinomaOrient JM, Sapira JD 2005
Cirrhosis with portal hypertensionOrient JM, Sapira JD 2005
Bilateral acute salpingitis with IUPOrient JM, Sapira JD 2005
Hemorrhaging ascites from hepatic tumorMabin, Gelfand 1974
Ischemic and gangrenous bowelKelley ML 1961
Rectus sheath hematomaGuthrie, Stanley 1996
Perforated duodenal ulcerEvans DM 1971
Splenic ruptureChung et al 1992
Percutaneous liver biopsyCapron et al 1977
Acute PancreatitisBosmann et al 2009
Ruptured abdominal aortic aneurysmArmour et al 1978

Epperla N et al. A Review of Clinical Signs Related to Ecchymosis. WMJ • APRIL 2015


Associated Persons

Alternative names
  • Cullen’s sign
  • Peri-umbilical ecchymosis

Controversies
  • The topographic location of the ecchymosis of Grey Turner and Cullen do not point to the aetiology with any degree of certainty.
  • Cullen sign lacks sensitivity and specificity for its original description. It has been described in acute pancreatitis, rectus sheath hematoma, splenic rupture, perforated ulcer, intra-abdominal cancer, and ruptured ectopic pregnancy, and as a complication of anticoagulation [Am J Med. 2008]

References

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the names behind the name

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and informatics. Asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | vocortex |

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