Rectus Sheath Hematoma Producing Cullen’s and Grey Turner’s Signs

 65-year-old chronic asthmatic female, who had been using oral steroids intermittently for many years, presented to the emergency department with severe abdominal pain for 6 hours. There was history of bouts of forceful coughing for the past 2 days. There was no history of anticoagulant use, trauma, bleeding diathesis in the family or any other hematological disease. She had stable vital signs. Abdominal examination revealed ecchymosis around the umbilicus and flanks, as shown in Figures 1 and 2, respectively (Cullen’s and Grey Turner’s sign, respectively). Tenderness was elicited around the umbilicus. A vague mass was palpable parallel to the umbilical region (dimensions 4 into 4 cm, indicated in Figure 2). Ultrasonography of the abdomen was unremarkable. All hematological parameters including the platelet counts and clotting times were within normal limits. Computerized tomography (CT) of the abdomen revealed a hematoma in the planes of the external and internal oblique muscles along with another hematoma in the rectus sheath.

The patient was managed conservatively. Cullen’s sign was first described by the gynecologist Thomas Stephen Cullen in a patient with a ruptured ectopic pregnancy while Grey Turner’s sign was first reported in 1920 by a surgeon, George Grey Turner, in a patient with acute pancreatitis. These signs are not pathognomonic for acute pancreatitis and have been described in various other disorders [1]. When associated with acute pancreatitis, the mortality rises to 37% [2].

1. Bhattacharya S. The Pancreas. In: Williams NS, Bullstrode CJK, O’Connel PR. (eds). Bailey and Love’s Short Practice of Surgery 25th edition. London: Edward Arnold Ltd; 2008. p.1140. 2. Mookadam F, Cikes M.Images in clinical medicine. Cullen’s and Turner’s signs. N Engl J Med 2005; 353:1386.