Clinical Picture Cullen’s and Turner’s sign associated with portal hypertension Sandeep Chauhan, Manisha Gupta , Atul Sachdev, Sanjay D’Cruz, Ikjot Kaur Lancet 2008; 372: 54 Department of Medicine (S Chauhan MD, M Gupta MD, Prof A Sachdev DM, S D’Cruz DM, I Kaur MBBS), Government Medical College & Hospital, Chandigarh, India Correspondence to: Sandeep Chauhan, Department of Medicine, Government Medical College & Hospital, Sector 32, Chandigarh, India schauhan@doctors.org.uk A 34-year old man with alcoholic cirrhosis and portal hypertension, presented with abdominal distension and pain of 2 weeks’ duration. Examination showed Cullen’s sign (periumbilical ecchymosis; figure A), Grey-Turner’s sign (ecchymosis on the abdominal flank; figure B) and ascites. A working diagnosis of acute pancreatitis seemed reasonable because both Cullen’s and Grey-Turner’s signs are associated with severe necrotising pancreatitis. Laboratory tests showed anaemia, normal leucocyte and platelet counts, and a mildly deranged coagulation profile, with an international normalised ratio of 1∙6. Serum amylase, lipase, and α-fetoprotein were within A B normal limits. A four-quadrant abdominal tap showed uniformly bloody fluid. Analysis of the fluid showed a leucocyte count of 0∙15×10⁹ per L (60% neutrophils), which was not consistent with an infectious cause, a high serum ascitic albumin gradient of 1∙4, and normal adenine deaminase values. Malignant cells were not seen and no organisms were detected on gram stain, Ziehl-Neelsen stain, or cultures. PCR for acid-fast bacilli was negative. Chest radiography was unremarkable. Tuberculin test (1TU) was negative. Ultrasonography and MRI of the abdomen showed hepatomegaly, ascites, and evidence of portal hypertension; the pancreas was normal on imaging studies. Upper gastrointestinal endoscopy showed grade II oesophageal varices. A diagnosis of haemoperitoneum possibly due to rupture of intraabdominal varices secondary to portal hypertension was made. Cullen’s and Grey-Turner’s signs have been described with intra-abdominal haemorrhage most commonly associated with pancreatitis. Rare associations include ectopic pregnancy, malignant disease (liver, abdominal metastasis), perforated duodenal ulcer, liver abscess, and splenic rupture. Figure: Intra-abdominal haemorrhage Cullen’s sign (A) and Turner’s sign (B). 54 www.thelancet.com Vol 372 July 5, 2008