Grey Turner sign: atraumatic abdominal ecchymosis, in particular – bruising of the flanks. George Grey Turner reported a ‘dirty-green‘ discolouration on both loins of a patient with acute pancreatitis (confirmed on operation)
- Incidence of 3-5% in patients with acute pancreatitis, associated with increased mortality (30-40%) and increased risk of pseudocyst formation. [Surg Gynecol Obstet. 1984 Oct;159(4):343-7.]
- CT scanning has helped to define the anatomic pathway by which extravasated pancreatic enzymes and their effects lead to these cutaneous discolorations. [Pancreas. 1998 May;16(4):551-5.].
- Extraperitoneal diffusion is from the anterior pararenal space between the two leaves of the posterior renal fascia and then to the lateral edge of the quadratus lumborum muscle.
- Communication may then extend to the posterior pararenal space and the structures of the flank wall. The lumbar triangle, a site of anatomic weakness on the flank wall, provides an external window into the internal proteolytic events.
George Grey Turner (1877–1951) was an English surgeon
1920 – Published paper on ‘Local discoloration of the abdominal wall as a sign of acute pancreatitis‘ citing two cases of acute pancreatitis with fat necrosis and retroperitoneal haemorrhage – Grey Turner sign
The first case from 1912 concerned a 54 year old female with three days of abdominal pain presenting with an area of discoloration (a bluish colour), about 6 inches in diameter involving the abdominal wall surrounding the umbilicus.
…the patient suffered from acute pancreatitis, with much effusion into the peritoneal cavity. She lived nine days after operation, and the post-mortem examination disclosed a sloughing pancreas with much fat necrosis
The second case from 1917 promoted the publication. “In a cursory examination of the voluminous literature on pancreatitis I have not observed any mention of this sign“
The tenderness over the gall-bladder region was very marked, and I now noticed two large discoloured areas in the loins. They were about the size of the palm of the hand, slightly raised above the surface, and of a dirty-greenish colour.
Alternate causes for Grey Turner Sign
|Intra-aortic balloon pump insertion||Rob, Williams 1961|
|Cardiac catheterization||Armour et al 1978|
|Sclerosing peritonitis||Pryor et al 2001|
|Rectus sheath hematoma||Guthrie, Stanley 1996|
|Ruptured abdominal aortic aneurysm||Armour et al 1978|
|Retroperitoneal necrotizing fasciitis||Pryor et al 2001|
|Ischemic and gangrenous bowel||Kelley ML 1961|
|Bilateral acute salpingitis with IUP||Orient JM, Sapira JD 2005|
|Acute Pancreatitis||Bosmann et al 2009|
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)
- Grey Turner’s sign
- The topographic location of the ecchymosis of Grey Turner and Cullen do not point to the aetiology with any degree of certainty.
- Grey Turner sign and Cullen sign may occur simultaneously, especially in patients with retroperitoneal haemorrhage.
- Grey Turner G. Local discoloration of the abdominal wall as a sign of acute pancreatitis. Br J Surg. 1920;7:394-395
- Cadogan M. Atraumatic Abdominal Ecchymosis. LITFL 2018
- Bem J, Bradley EL 3rd. Subcutaneous manifestations of severe acute pancreatitis. Pancreas. 1998 May;16(4):551-5. [PMID 9598819]
- Chhabra P, Rana SS, Sharma V, Sharma R, Bhasin DK. Grey Turner’s sign in acute necrotizing pancreatitis. Ann Gastroenterol. 2015 Jan-Mar; 28(1): 147.. [PMC4289992]
- Dickson AP, Imrie CW. The incidence and prognosis of body wall ecchymosis in acute pancreatitis. Surg Gynecol Obstet. 1984 Oct;159(4):343-7. [PMID 6237447]
- Epperla N, Mazza JJ, Yale SH. A Review of Clinical Signs Related to Ecchymosis. WMJ. 2015 Apr;114(2):61-5. [PMID 26756058]
- Meyers MA, Feldberg MA, Oliphant M. Grey Turner’s sign and Cullen’s sign in acute pancreatitis. Gastrointest Radiol. 1989 Winter;14(1):31-7. [PMID 2910743]
- Chung KM, Chuang SS. Cullen and Grey Turner signs in idiopathic perirenal hemorrhage. CMAJ. 2011 Nov 8;183(16):E1221 [PMC3216450]
- Mookadam F, Cikes M. Images in clinical medicine. Cullen’s and Turner’s signs. N Engl J Med. 2005 Sep 29;353(13):1386. [PMID 16192483]