Home / Visual Diagnosis # 16 : Answers

Visual Diagnosis # 16 : Answers


Periumbilical ecchymosis, also known as Cullen’s Sign (A),results from tracking of blood from the retroperitoneum to the umbilicus along the gastrohepatic and falciform ligament and then subsequently to subcutaneous umbilical tissues through the connective tissue covering of the round ligament. In this patient, Cullen’s sign was associated with acute pancreatitis and a result of liberated pancreatic enzymes causing the diffusion of fat necrosis and inflammation with retroperitoneal or intraabdoinal bleeding. 

Grey Turner’s sign (B) is produced by hemorrhagic fluid spreading from the posterior pararenal space to the lateral edge of the quadratus lumborum muscle and thereafter to the subcutaneous tissues by means of a defect in the fascia of the flank. In this patient these signs, although not specific, are associated with severe acute pancreatitis and a high mortality.

Cullens sign and Grey turners sign - 60secondEM


Other signs which could indicate possible retroperitoneal or intraabdominal bleeding include:  


Fox’s Sign: is secondary to blood seeping along the fascia of psoas and iliac and can result in ecchymosis of the upper lateral aspect of the patient’s thigh resulting in an ecchymosis having a sharply demarcated superior border paralleling but inferior to the inguinal ligament. This sign has also been described in other settings including strangulated ileum, urethral instrumentation, reaction to subcutaneous injections, and pulmonary infarction.

Fox's sign

Groin and Scrotum:

Stabler’s sign (C) Ecchymosis over the inguinal ligament. In some cases of retroperitoneal hemorrhage, the blood may extravasate and cause discoloration of the inguinal-pubic area.  This sign originally was described in adult patients suffering from acute hemorrhagic pancreatitis or ruptured ectopic pregnancy. Subsequently, it has been reported in various other conditions including AAA rupture. Although rare, this sign is most commonly identified in neonates secondary to adrenal hemorrage. Obstetric injury, perinatal hypoxia, and sepsis are common causes for neonatal adrenal hemorrhage. A nonsurgical approach is generally recommended when ecchymotic sign is present in a neonate. However, rarely, it may be due to ruptured neuroblastoma, in which case prompt search for underlying adrenal malignancy should be undertaken.

Bryant’s Sign (D) Ecchymosis of the scrotum resulting from blood tracking along the retroperitoneum and into the inguinal canal and tracking down the spermatic cord. Bryant’s sign can occur in the setting of retroperitoneal bleeding and should raise concern for the possibility of a ruptured AAA or lacerated viscus (this pediatric image was due to was a lacerated liver during a difficult delivery). The ecchymosis may be continuous or patchy, bilateral or unilateral, and may involve the lower extremities. This sign is typically first seen 3 or 4 days after the initial symptoms of pain, but may present hours or even weeks after rupture. The delay is accounted for by the time it takes blood to extravasate the facial planes to reach its final destination, which is presumably influenced by the volume of blood loss and patient’s dependent position.

Bryant's and Stabler's Signs - 60secondEM





  1. Mookadam F, Cikes M. Cullen’s and Turner’s signs. N Engl J Med 2005;353:1386-1386
  2. Bem J, Bradley EL III. Subcutaneous manifestations of severe acute pancreatitis. Pancreas 1998;16:551-555
  3. Gore RM, Balfe DM, Aizenstein RI, Silverman PM. The great escape: interfascial decompression planes of the retroperitoneum. AJR Am J Roentgenol 2000;175:363-370
  4. Fox JA. A diagnostic sign of extraperitoneal hemorrhage. Br J Surg 1966;53:193-195
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  6. Ratzan RM, Donaldson MC, Foster JH, Walzak MP. The blue scrotum sign of Bryant: a diagnostic clue to ruptured abdominal aortic aneurysm. J Emerg Med 1987;5:323-329