CULLEN'S SIGN: SYMPTOMS, CAUSES, TREATMENT - MEDICINE - 2025

The Cullen sign is a clinical symptom having a purple or violet and can be found in the central part of the abdomen, in the periumbilical skin. It is visible on physical examination, is not particularly painful, and is indicative of bleeding from an organ within the abdominal cavity.

The hematoma forms in the umbilical region when the blood reaches the round ligament of the liver, which communicates that organ with the navel. This sign occurs in serious and life-threatening illnesses.

By Herbert L. Fred, MD and Hendrik A. van Dijk - http://cnx.org/content/m14904/latest/, CC BY 2.0, commons.wikimedia.org

The most common disease in which the patient manifests it is acute necrotizing pancreatitis, but only when the head of the pancreas is affected. It can also be present in women with a ruptured ectopic pregnancy. In these types of pregnancies, the embryo usually implants in the uterine tubes.

Cullen's sign is associated with another with similar characteristics, Gray Turner's sign, which is the violet coloration of the skin on the flanks of the abdomen.

Description and pathophysiology

Cullen's sign was described in by Canadian gynecologist Dr. Thomas S. Cullen at John Hopkins Hospital in Baltimore, USA.

Cullen devoted much of her professional life to the study of uterine cancer and ectopic pregnancy. In 1918 he received a 38-year-old patient who reported abdominal pain of 3 weeks of evolution.

By Doris Ulmann (1882-1934) - http://www.photogravure.com/collection/searchResults.php?page=7&artist=Ulmann,%20Doris&view=medium&file=Ulmann_03_28, Public Domain, commons.wikimedia.org

One week after the onset of abdominal pain, he reported the appearance of a bluish color around the navel without having suffered trauma in this area.

In his article "A New Sign in Ruptured Ectopic Pregnancy", Dr. Cullen described it as follows: "The bluish appearance of the navel that is not associated with trauma along with a para-uterine mass completes the pregnancy diagnosis. extra-uterine almost certainly ”.

Since that publication, the violet or bluish discoloration of the umbilicus related to bleeding within the abdominal cavity has been called Cullen's sign, regardless of etiology.

Cullen's sign is a rare manifestation that is present in less than 5% of patients with intra-abdominal bleeding. However, in those cases in which it is observed it is indicative of serious disease.

It is associated with another skin sign, the Gray Turner sign. In this case, the hematoma is found on the lateral part of the abdomen, the flanks, and is found in patients with retroperitoneal bleeding, that is, in those cases in which the bleeding organ is located behind the layer that covers the abdomen..

Both the Gray Turner and Cullen signs are commonly associated with necrotizing hemorrhagic pancreatitis, although they can be present in several pathologies; and it is very bad prognosis to find both in the same patient.

Pathophysiology

The violet or bluish coloration, characteristic of Cullen's sign, is seen in the umbilicus due to bleeding into the abdomen that reaches the falciform ligament of the liver.

This structure communicates with the navel through the round ligament of the liver, which is a vestige of the umbilical vein of the fetus which after birth is completely closed, giving rise to this element.

From Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below) Bartleby.com: Gray's Anatomy, Plate 502, Public Domain, commons.wikimedia.org

In the case of patients with necrotizing pancreatitis, there is the presence of inflammatory fluid around the pancreas which contains enzymes that degrade the tissue and are capable of penetrating the muscle until reaching the subcutaneous cellular tissue of the navel.

The bluish color, typical of bruises, normally forms when hemoglobin breaks down.

Associated pathologies

Acute pancreatitis

Acute pancreatitis is inflammation of the pancreas as a result of an exaggerated activation of the pancreatic digestive enzymes.

It is mainly associated with obstruction of the pancreatic duct outlet into the duodenum caused by stones or lithiasis stuck in the bile duct.

In its acute phase, the patient with pancreatitis refers to pain that is located in the epigastrium and, as time passes, the abdomen and back are taken at that level. This symptom is described as abdominal band pain and is typical of pancreatitis.

One of the complications of acute pancreatitis is hemorrhagic necrotizing pancreatitis. It occurs in 10% of cases of acute pancreatitis.

It occurs when digestive enzymes continue the process of self-digestion of pancreatic tissue despite treatment, causing necrosis of the pancreatic surface.

Cases of acute pancreatitis with severe necrosis can lead to the installation of serious complications in the patient including diabetes. In 30% of cases, hemorrhagic necrosis of the pancreas is fatal.

Hemorrhagic necrotizing pancreatitis is usually located in the body and tail of the pancreas, but it can also reach the head of that organ.

When the necrosis reaches the area of ​​the head of the pancreas, the Cullen's sign can be seen. In most cases in which there are skin manifestations, the Gray Turner sign is observed.

By Herbert L. Fred, MD and Hendrik A. van Dijk - http://cnx.org/content/m14942/latest/, CC BY 2.0, commons.wikimedia.org

The presence of both signs indicates that the entire pancreatic parenchyma is compromised. This situation can bring serious consequences to the patient including diabetes and even death.

In general, pancreatitis is a self-limited condition, this means that it does not need specific treatments since the improvement occurs by itself.

Patients must be hospitalized in an intensive care unit (ICU) to monitor their fluid balance. They must stay hydrated and in control of pain.

The treatment depends on the cause. When stones are obstructing the passage of pancreatic fluid into the duodenum, an invasive procedure must be performed to remove the stones and allow that fluid to resume its normal course.

In order for the pancreas to be able to rest from its work in digestion, the administration of nutrition through the vein or parenteral nutrition is indicated.

In the case of necrotizing pancreatitis, antibiotics should be indicated to avoid the formation of peri-pancreatic abscesses.

When there is very extensive necrosis or large abdominal abscesses have formed, surgical drainage is chosen. This procedure is reserved for cases in which non-invasive techniques have failed.

Others

Other associated pathologies are ectopic pregnancy and abdominal trauma.

Treatment

Cullen's sign is not a pathology as such, but the physical evidence of a primary disease of the abdomen.

Should the bruise become hard, painful, or contaminated, appropriate medications should be administered for each of these complications.

Gel or cream anticoagulants can improve hardening by helping to finish dissolving the clot.

In the case of pain, it can occur when the hematoma covers a very large area. Nonsteroidal pain relievers, such as aspirin and diclofenac, generally improve pain.

The most serious complication is contamination of the hematoma by bacteria. When the bruised area becomes warm and the skin is very sensitive, infection is very likely.

In these cases, the intravenous administration of antibiotics should be started immediately to avoid other associated pathologies such as cellulitis, abscess and even skin necrosis.

References

1. Bendersky, V. A; Mallipeddi, M. K; Sloth; Pappas, TN (2016). Necrotizing pancreatitis: challenges and solutions. Clinical and experimental gastroenterology. Taken from: ncbi.nlm.nih.gov
2. Mookadam, F; Cikes, M. (2005). Images in clinical medicine. Cullen's and Turner's signs. N. Engl. J. Med. Taken from: ncbi.nlm.nih.gov
3. Birnaruberl, CG; RiBe, M; Kettner, M; Schnabel, A; Ramsthaler, F; Verhoff MA. (2016). So-called skin signs in acute pancreatitis. Taken from: ncbi.nlm.nih.gov