GRAY-TURNER SIGN: WHAT IT IS AND ASSOCIATED PATHOLOGIES - MEDICINE - 2025

The Gray Turner sign is a clinical manifestation in which there is a violet coloration, like a bruise, towards the skin of the flanks, at any level of the abdomen of patients without trauma to that area.

Generally, the Gray Turner sign is associated with patients with serious pathologies that cause retroperitoneal bleeding. The peritoneum is the layer that covers the abdomen, all the organs that are behind that layer are called retroperitoneal organs. The most common pathology in which the patient manifests this clinical sign is acute necrotizing pancreatitis.

By Harry Lister -, CC BY 4.0, The presence of the Gray Turner sign is associated with another sign with similar characteristics, Cullen's sign, which is the violet coloration of the periumbilical skin. When both signs appear in a patient with pancreatitis, the prognosis is very poor.

What is the Gray Turner sign?

The Gray Turner sign was described in 1920 by the English surgeon George Gray Turner who described the manifestation of ecchymosis or violet color on the abdominal flanks, in patients with severe acute pancreatitis.

In this regard he wrote: “I have noticed two areas of discoloration towards the flanks. They are the size of the palm of the hand, a little raised and of a violet and gray-green color. They manifest with edema but without pain ”.

Although Gray Turner described this manifestation as a specific sign in patients with acute pancreatitis, the eponymous is used to describe the violet coloration of the flanks in patients with any pathology that causes retroperitoneal bleeding.

This eponymous should not be used to describe the hematoma of the skin due to different pathologies, including direct trauma to the flanks. In any case it is a warning sign. It means a serious disease with a poor prognosis.

Pathophysiology

The way in which fluid passes into the retroperitoneum and into the subcutaneous cellular tissue of the flanks has been extensively studied.

The coloration on the flanks is observed because the diseased retroperitoneal organ becomes inflamed, this causes it to begin to transfer fluid to the rest of the retroperitoneal cavity. Upon reaching the level of the kidneys, fluid begins to accumulate.

From Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below) Bartleby.com: Gray's Anatomy, Plate 1220Translated from Image: Gray1220.svg, Public Domain, https: //commons.wikimedia. org / w / index.php? curid = 4797101

In general, this inflammatory fluid contains some enzymes that degrade the tissue and pass through the muscle until it reaches the subcutaneous cellular tissue of the flanks.

Once the inflammatory fluid builds up on the flanks, it begins to break down the subcutaneous cellular tissue and blood products normally found there causing a change in hemoglobin, which is what ultimately gives the characteristic color of Grey's sign. Turner.

Retroperitoneum

The retroperitoneum is the region of the abdominal cavity and the pelvic cavity, which lies behind the peritoneum.

The peritoneum is a membrane that lines the intra-abdominal organs. However, there are organs that lie behind it forming a second area within the abdomen limited in front by the peritoneal lamina.

Some of the organs found in the retroperitoneal cavity are the kidneys and ureters, the aorta and vena cava, some muscles, such as the diaphragm and psoas, as well as the rectum and pancreas.

By Modified from Henry Gray (1827–1861) - Wikimedia Commons File: Gray1035.png, CC BY-SA 3.0, The symptoms of the retroperitoneal organs are late and difficult to assess. Retroperitoneal tumors, for example, tend to grow long before the patient is aware of their presence. Diagnosis is often made through imaging tests such as computerized axial tomography.

Review that around 80% of tumors in this area are malignant.

The pancreas is a retroperitoneal organ that is responsible for the digestion of fats and carbohydrates and for controlling blood sugar. The main pathological condition of the pancreas is acute pancreatitis and one of its complications is necrotizing pancreatitis.

Associated pathologies

Acute pancreatitis

Acute pancreatitis is inflammation of the pancreas that results from an exaggerated activation of pancreatic digestive enzymes. This reaction triggers tissue damage by self-digestion.

The most common causes are obstruction of the pancreatic duct by stones from the gallbladder and alcoholism.

By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See «Book» section below) Bartleby.com: Gray's Anatomy, Plate 1100, Public Domain, https://commons.wikimedia.org/w/index. php? curid = 530038

Acute pancreatitis is characterized by moderate pain located in the epigastric region and radiating to both sides of the abdomen forming a kind of band. The pain increases as time passes.

It is difficult to predict the course of this disease. In most cases it is self-limiting or improves by treating the condition that causes it. However, there are complicated cases with a very poor prognosis in which the patient's life is compromised.

One of the complications of acute pancreatitis is necrotizing pancreatitis. In these cases, the digestive enzymes continue in the process of self-digestion of the pancreatic tissue, forming a true necrotic tissue that can become contaminated.

Cases of acute pancreatitis with severe necrosis can lead to the installation of serious complications in the patient including diabetes and even death.

Ruptured ectopic pregnancy

Ectopic pregnancy is a condition in which the implantation of the embryo occurs in a site other than the uterus. The most common site of ectopic pregnancy is the fallopian tubes.

By BruceBlaus - Own work, CC BY-SA 4.0, As time goes by, the embryo grows to form the fetus. However, when being in a limited space, such as the lumen of the fallopian tubes, there comes a time that this tissue gives way and breaks causing a large pelvic hemorrhage.

Gray Turner's sign can be found in cases of ruptured ectopic pregnancy, especially located towards the sides of the pelvis. It is not found frequently, since this pathology is an absolute emergency and most of the time it is treated before a specific symptomatology is installed.

Abdominal trauma

In blunt abdominal trauma, which occurs when the abdomen collides with a surface without damaging the soft tissues but causing great internal damage, there may be bleeding from organs that are difficult to assess, especially at the beginning.

When the Gray Turner sign is evident in a patient with blunt abdominal trauma, in whom no other causes of bleeding are observed, retroperitoneal bleeding should be considered immediately. Some retroperitoneal organ or muscle may be seriously injured and may be the cause of the clinical manifestation.

References

1. Guldner GT, Magee EM. Gray-Turner Sign. (2019). StatPearls. Treasure Island (FL). Taken from: ncbi.nlm.nih.gov
2. Boumitri, C; Brown, E; Kahaleh, M. (2017). Necrotizing Pancreatitis: Current Management and Therapies. Clinical endoscopy. Taken from: ncbi.nlm.nih.gov
3. 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
4. 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
5. Fan, Z; Zhang, Y. (2017). Gray Turner's and Cullen's signs induced by spontaneous hemorrhage of the abdominal wall after coughing. Annals of surgical treatment and research. Taken from: ncbi.nlm.nih.gov