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.
Original publication: (n=1)
1918 – Thomas 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
Alternate causes for Cullen Sign
|Retroperitoneal necrotizing fasciitis||Pryor et al 2001|
|Strangulated umbilical hernia||Orient JM, Sapira JD 2005|
|Strangulation of ileum with hemorrhage||Orient JM, Sapira JD 2005|
|Renal sarcoma metastatic to the peritoneum||Orient JM, Sapira JD 2005|
|Ovarian cyst hemorrhage||Orient JM, Sapira JD 2005|
|Hypothyroid myopathy||Orient JM, Sapira JD 2005|
|Hepatocellular carcinoma||Orient JM, Sapira JD 2005|
|Cirrhosis with portal hypertension||Orient JM, Sapira JD 2005|
|Bilateral acute salpingitis with IUP||Orient JM, Sapira JD 2005|
|Hemorrhaging ascites from hepatic tumor||Mabin, Gelfand 1974|
|Ischemic and gangrenous bowel||Kelley ML 1961|
|Rectus sheath hematoma||Guthrie, Stanley 1996|
|Perforated duodenal ulcer||Evans DM 1971|
|Splenic rupture||Chung et al 1992|
|Percutaneous liver biopsy||Capron et al 1977|
|Acute Pancreatitis||Bosmann et al 2009|
|Ruptured abdominal aortic aneurysm||Armour et al 1978|
Epperla N et al. A Review of Clinical Signs Related to Ecchymosis. WMJ • APRIL 2015
- John Henry Bryant and Bryant sign (1903)
- Thomas Stephen Cullen and Cullen sign (1918)
- George Grey Turner and Grey Turner sign (1919)
- Francis Edward Stabler and Stabler Sign (1934)
- John Adrian Fox and Fox sign (1966)
- Cullen’s sign
- Peri-umbilical ecchymosis
- 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]
- Cullen TS. A new sign in ruptured extrauterine pregnancy. American journal of obstetrics and diseases of women and children. 1918; 78: 457 [Cullen Sign]
- Chung KM, Chuang SS. Cullen and Grey Turner signs in idiopathic perirenal hemorrhage. CMAJ. 2011 Nov 8;183(16):E1221
- Harris S, Naina HV. Cullen’s sign revisited. Am J Med. 2008 Aug;121(8):682-3.
- 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(5): 143–146.
- Cadogan M. Atraumatic Abdominal Ecchymosis. LITFL 2018
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