Stabler sign: Non-traumatic abdominal skin ecchymosis in the inguinal-pubic area associated with intra-abdominal haemorrhage, originally described in ectopic pregnancy
Original publication: (n=1)
1934 – Stabler published a paper titled ‘A case showing Cullen’s sign‘ concerning a patient presenting with an ectopic pregnancy: with left illiac fossa pain of fourteen days duration and ilioinguinal ‘bruising’, 7 weeks post last menstrual period.
C.S. Aged 34: One inch below and to the left of the umbilicus was a purple, almost black, clearly cut mark 3/4 in. by 1/4 in. shaped like a comma. Below it, about the junction of the upper third and lower two-thirds of the distance from the umbilicus to the pubes, was a ” bruise,” bluish in colour, about 1 in. in diameter, whilst abutting on the inguinal fold was a reddish-purple mark like a fresh bruise, shaped roughly like the ace of clubs, about 2 in. in diameter. The whole was within the triangle formed by the midline and a line drawn to the umbilicus from the middle of the left inguinal ligament. On bimanual examination a soft mass the size of a hen’s egg was evident in the left tubal region.
At operation the distal half of the left Fallopian tube contained an ampullary pregnancy surrounded by blood clot. The tube was not ruptured, but a little dark blood was oozing from the abdominal ostium. In the peritoneal cavity there were not more than 3 or 4oz (88-118mL) of dark fluid blood…incision into the subcutaneous fatty tissue proved the stains to be true ecchymoses.
It is an interesting speculation as to how the blood reaches the subcutaneous tissues. In the present reported case I forecast that there would be an intraligamentary rupture of the tube with a broad ligament haematoma from which blood had tracked up extraperitoneally as far as the umbilicus, possibly following the obliterated hypogastric artery by which the lateral spread of the discoloration was limited.
- Initially described as an inguinal-pubic extension of the peri-umbilical ecchymosis of Cullen sign
- Further cases of bruising to the inguinal-pubic area reported with AAA rupture and acute hemorrhagic pancreatitis
- Although rare, this sign has most commonly been identified in neonates secondary to adrenal hemorrhage. This is associated with obstetric injury, perinatal hypoxia, and sepsis [Urology. 2002 Apr;59(4):601]. Rarely, it may be due to ruptured neuroblastoma.
- 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)
- Stabler F. A case showing Cullen’s sign. Br Med J. 1934;2(3840):255-256.
- Cadogan M. Atraumatic Abdominal Ecchymosis. LITFL 2018
- Avolio L, Fusillo M, Ferrari G, Chiara A, Bragheri R. Neonatal adrenal hemorrhage manifesting as acute scrotum: timely diagnosis prevents unnecessary surgery. Urology. 2002 Apr;59(4):601. [PMID 11927330]
- Duman N, Oren H, Gulcan H, Kumral A, Olguner M, Ozkan H. Scrotal hematoma due to neonatal adrenal hemorrhage. Pediatr Int. 2004 Jun;46(3):360-2. [PMID 15151558]
- Raveenthiran V, Cenita S, Viswanathan P. Stabler’s sign revisited in a spontaneously ruptured neuroblastoma of the newborn. Am J Perinatol. 2008 Jan;25(1):17-20. [PMID 18050035]
- Epperla N, Mazza JJ, Yale SH. A Review of Clinical Signs Related to Ecchymosis. WMJ. 2015 Apr;114(2):61-5. [PMID 26756058]