Eponymythology: Atraumatic Abdominal Ecchymosis

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Overview

We review the original descriptions of 5 eponymous signs (n=6) associated with non-traumatic abdominal ecchymosis.

These commonly cited eponyms involving the abdominal wall and flanks (Grey Turner, Cullen and Stabler); scrotum (Bryant) and upper thigh (Fox) may be useful clues directing the examiner to consider potentially serious causes of abdominal pathology.

Cullen sign

Thomas Stephen Cullen (1869–1953) was a Canadian gynecologist

Non-traumatic peri-umbilical ecchymoses associated with intra-abdominal haemorrhage, originally described in ectopic pregnancy – Cullen sign

Original publication: (n=1)

1918 – Cullen first described a bluish black discoloration of the periumbilical skin in a female patient with a ruptured extrauterine pregnancy with ‘no history of injury

Cullen originally described the finding at the 43rd annual meeting of the Transactions of the American gyecological society, Pennsylvania May 16-18 1918 [Am J Obstet Gynecol 1918;78:457]. He concluded that the umbilical appearance was due to intra-abdominal haemorrhage secondary to an ectopic pregnancy

+ TS Cullen original description

cullen sign

Clinical context

  • Despite the original description, most literature relates Cullen sign of periumbilical ecchymosis to acute pancreatitis (being recorded in 1-3% cases) rather than secondary to an ectopic pregnancy.
  • In most described cases, it takes 3-5 days for Cullen sign to present and the sign been associated with a broad range of clinical conditions

+ Alternate causes for Cullen Sign

Cause Reference
Ruptured abdominal aortic aneurysm Armour et al 1978
Acute Pancreatitis Bosmann et al 2009
Percutaneous liver biopsy Capron et al 1977
Splenic rupture Chung et al 1992
Perforated duodenal ulcer Evans DM 1971
Rectus sheath hematoma Guthrie, Stanley 1996
Ischemic and gangrenous bowel Kelley ML 1961
Hemorrhaging ascites from hepatic tumor Mabin, Gelfand 1974
Bilateral acute salpingitis with IUP Orient JM, Sapira JD 2005
Cirrhosis with portal hypertension Orient JM, Sapira JD 2005
Hepatocellular carcinoma Orient JM, Sapira JD 2005
Hypothyroid myopathy Orient JM, Sapira JD 2005
Ovarian cyst hemorrhage Orient JM, Sapira JD 2005
Renal sarcoma metastatic to the peritoneum Orient JM, Sapira JD 2005
Strangulation of ileum with hemorrhage Orient JM, Sapira JD 2005
Strangulated umbilical hernia Orient JM, Sapira JD 2005
Retroperitoneal necrotizing fasciitis Pryor et al 2001

Epperla N et al. A Review of Clinical Signs Related to Ecchymosis. WMJ • APRIL 2015

Grey Turner sign

George Grey Turner (1877–1951) was an English surgeon

Non-traumatic abdominal ecchymosis, in particular – bruising of the flanks associated with retroperitoneal haemorrhage, originally described in acute pancreatitis – Grey Turner sign

Original publication: (n=1)

1919 – George Grey Turner submitted his article for publication as following a “…cursory examination of the voluminous literature on pancreatitis”, where he was unable to “…observe any mention of this sign”

1920 – George Grey Turner published ‘Local discoloration of the abdominal wall as a sign of acute pancreatitis‘ citing two cases of acute pancreatitis with fat necrosis and retroperitoneal haemorrhage [Br J Surg. 1920;7:394-395]

  • Case 1 [1912]: 54 year old female with three days of abdominal pain presenting with an area of discoloration (a bluish colour), about 6 inches in diameter involving the abdominal wall surrounding the umbilicus (see Cullen sign…).

“…the patient suffered from acute pancreatitis, with much effusion into the peritoneal cavity. She lived nine days after operation, and the post-mortem examination disclosed a sloughing pancreas with much fat necrosis

  • Case 2 [1917]: 53 year old male soldier with a history of recurrent bouts of self-limiting abdominal pain. He presented with unremitting abdominal pain and a rigid abdomen…looking ‘distinctly toxic’

The tenderness over the gall-bladder region was very marked, and I now noticed two large discoloured areas in the loins. They were about the size of the palm of the hand, slightly raised above the surface, and of a dirty-greenish colour.

+ Image of Grey Turners Sign: Original Photo: 1917. Colourised: Ercleve T. 2018

Grey Turners Sign Original Photo 1919 COLOR
Grey Turners Sign: Original Photo: 1917. Colourised: 2017 Tor Ercleve

Clinical context

  • Incidence of 3-5% in patients with acute pancreatitis, associated with increased mortality (30-40%) and increased risk of pseudocyst formation. [Surg Gynecol Obstet. 1984 Oct;159(4):343-7.]
  • CT scanning has helped to define the anatomic pathway by which extravasated pancreatic enzymes and their effects lead to these cutaneous discolorations. [Pancreas. 1998 May;16(4):551-5.]. Extraperitoneal diffusion from the anterior pararenal space between the two leaves of the posterior renal fascia; to the lateral edge of the quadratus lumborum muscle and may then extend to the posterior pararenal space and the structures of the flank wall. The lumbar triangle, a site of anatomic weakness on the flank wall, provides an external window into the internal proteolytic events.
  • In most described cases, it takes 3-5 days for Grey Turner sign to present and the sign been associated with a broad range of clinical conditions

+ Alternate causes for Grey Turner Sign

Cause Reference
Acute Pancreatitis Bosmann et al 2009
Bilateral acute salpingitis with IUP Orient JM, Sapira JD 2005
Ischemic and gangrenous bowel Kelley ML 1961
Retroperitoneal necrotizing fasciitis Pryor et al 2001
Ruptured abdominal aortic aneurysm Armour et al 1978
Rectus sheath hematoma Guthrie, Stanley 1996
Sclerosing peritonitis Pryor et al 2001
Cardiac catheterization Armour et al 1978
Intra-aortic balloon pump insertion Rob, Williams 1961

Epperla N et al. A Review of Clinical Signs Related to Ecchymosis. WMJ • APRIL 2015

Stabler sign

Francis Edward Stabler (1902–1967) was an English gynaecologist and surgeon

Non-traumatic abdominal skin ecchymosis in the inguinal-pubic area associated with intra-abdominal haemorrhage, originally described in ectopic pregnancy – Stabler sign

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

Clinical examination

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.”

Operative findings

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.

Hypotheses

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.

Clinical context

  • 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.

Fox sign

John Adrian Fox English surgeon

Non-traumatic ecchymosis over the upper outer aspect of the thigh. Ecchymosis is parallel with, but distal to the inguinal ligament with a well demarcated upper border defined by attachment of the membranous layer of the superficial fascia (Scarpa’s fascia). Originally described with retroperitoneal haemorrhage. – Fox Sign

Original publication: (n=2)

1966 – JA Fox (London) detailed 2 fatal cases of non-traumatic ecchymosis determined as a diagnostic sign of retroperitoneal haemorrhage. In both cases, this sign was noticed late in the course and produced by tracking of the fluid extraperitoneally along the fascia of psoas and iliacus beneath the inguinal ligament until it became subcutaneous in the upper thigh.

Case 1: Fourteen hours after admission bruising was noted in both upper outer thighs. It had a sharp upper margin, was dark blue, and was quite distinct from the patchy mottling of her legs below [Post mortem: acute suppurative pancreatitis]

+ Image of Case 1: Fox’s Sign, 1966. Colourized: Ercleve T. 2018

Fox's Sign 1966

Case 2: A man, of about 50…with severe abdominal pain and circulatory collapse. Resuscitatory measures were of no avail and he died within 24 hours of admission. Before death bruising was noticed in the upper outer aspect of one thigh. He had not been given injections in this region and no other cause for the bruising was apparent. [Post-mortem: dissecting and ruptured abdominal aortic aneurysm]

Hypotheses

..seems likely that the clinical sign seen in the above 2 cases is produced by tracking of the fluid extraperitoneally along the fascia of psoas and iliacus beneath the inguinal ligament until it becomes subcutaneous in the upper thigh.

Cadaver Experiment: This sign has been reproduced in two stages in the recent cadaver. A solution of methylene blue in normal saline was injected from a height of 10 feet into the loin for several hours. The blue dye was then traced by dissection until it was seen to pass beneath the inguinal ligament”

Clinical context

  • Initially recorded in acute pancreatitis and ruptured aortic aneurysm
  • Subsequently described with strangulated ileum, urethral instrumentation, reaction to subcutaneous injections, and pulmonary infarction.

Bryant sign

John Henry Bryant (1867–1906) was an English physician

Scrotal ecchymosis associated with ruptured abdominal aortic aneurysm (AAA) – Bryant sign

Original publication: (n=1)

1903 – Bryant described scrotal ecchymosis associated with ruptured AAA during two lectures in which he had evaluated 18,678 necropsies and the 325 deaths secondary to abdominal aortic aneurysm rupture. [Clin Jour. 1903;23:71-80].

In these two articles Bryant describes the diffuse nature of the atheromatous changes, the possible clinical presentation of AAA as apparent renal colic, and the scrotal and abdominal discolourations as diagnostic clues

In one case blood was effused into the right spermatic cord, and the corresponding half of the scrotum was much ecchymosed…When blood is extravasated into the anterior abdominal wall ecchymoses may appear…‘ [Clin Jour. 1903;23:79]

+ JH Bryant original description

Bryant sign

1987 – RM Ratzan et al proposed eponymous historical attribution of lower abdominal/scrotal discolouration secondary to aortic aneurysmal disease to John Henry Bryant. [J Emerg Med. 1987 Jul-Aug;5(4):323-9]

Clinical context

  • Bryant sign is rare.
  • Blood must transverse the inguinal canal and spermatic cord down to the subcutaneous scrotal tissue.
  • It requires specific pathological circumstances such as a closed (retroperitoneal hematoma) or sealed (surrounding retroperitoneal and aortic tissue) rupture of abdominal aortic aneurysm. It requires a slow rate of aneurysmal leakage and a prolonged interval prior to final rupture.
  • Most recorded cases of Bryant sign occur three to six days after onset of abdominal symptoms – Pearlman (1940), Barratt-Boyes (1957) and Beebe (1958).

Summary

The original publications of the eponymised cases often include careful clinical descriptions and anatomopathophysiological hypotheses in an era devoid of adjunctive diagnostic aids. However, we now have the benefit of comparing the diagnostic validity of the signs in a vast array of published clinical cases illuminated by enhanced imaging techniques and a more in-depth understanding of pathophysiology.

The original n=1 published cases represent a springboard for us to review arcane terminology by first understanding the historical folksonomy and then to redefine in clinical context to reduce descriptive confusion and narrowing of our diagnostic differentials.

For example, in 1918 Cullen described a single case of umbilical ecchymoses in a patient with an ectopic pregnancy. Over the subsequent 100 years at least 17 alternate diagnoses have been ascribed to the external abdominal manifestation of his eponymous sign.

Of significant note, the topographic location of atraumatic abdominal ecchymosis does not point to the aetiology with any degree of certainty and these signs may be potentiated by anticoagulation therapy or qualitative/quantitative platelet abnormalities.

Of course there is a certain historical interest in relating these signs to pioneers in descriptive medicine. However, we may be better to describe ‘non-traumatic abdominal wall ecchymosis’ as a potential sign of intraperitoneal or retroperitoneal pathology which requires further evaluation…

[…unless you enjoy a ‘down and dirty‘ eponym spat with the inpatient specialists? Then read on, and prepare your semantygdala for the symphonic cacophony of ‘I told you so...’]

References

  • Cullen TS. A new sign in ruptured extrauterine pregnancy. Am J Obstet Gynecol 1918;78:457
  • Grey Turner G. Local discoloration of the abdominal wall as a sign of acute pancreatitis. Br J Surg. 1920;7:394-395
  • Stabler F. A case showing Cullen’s sign. Br Med J. 1934;2(3840):255-256.
  • Fox JA. A diagnostic sign of extraperitoneal hemorrhage. Br J Surg. 1966 Mar;53(3):193-5. [PMID 5907449]
  • Bryant JH. Two clinical lectures on aneurysm of the abdominal aorta: lecture 1. Clin Jour. 1903;23:71-80.
  • Epperla N, Mazza JJ, Yale SH. A Review of Clinical Signs Related to Ecchymosis. WMJ. 2015 Apr;114(2):61-5. [PMID 26756058]

Eponymythology: Atraumatic Abdominal Ecchymosis Mike Cadogan

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Author: Mike Cadogan

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