Grey-Turner Sign


Article Author:
Gregory Guldner


Article Editor:
Edward Magee


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


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Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
1/13/2019 11:06:13 PM

Definition/Introduction

Grey Turner’s sign refers to an uncommon subcutaneous manifestation of intra-abdominal pathology manifesting as ecchymosis or discoloration of the flanks.[1] Classically it is associated with severe acute necrotizing pancreatitis often in association with Cullen’s sign (periumbilical ecchymosis). It may also be seen in many other conditions that result in intra-abdominal or retroperitoneal hemorrhage. The discoloration may be green, yellow, or purple depending on the degree of red blood cell (RBC) breakdown in the abdominal wall tissues and may not occur until several days into the course of an illness.

Issues of Concern

In an article published in 1920, British surgeon George Grey Turner, MBBS (1877-1951), described finding subcutaneous discoloration of the flanks in patients found to have severe pancreatitis. Referring to a patient with severe pancreatitis he wrote, “I now noticed two large discolored 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 color. There was a little edema, with pitting on pressure, but there was no pain or tenderness.” Since that publication, the exam finding of ecchymosis of the flank in association with intra-abdominal bleeding has carried Dr. Turner’s name. However, descriptions of non-traumatic abdominal wall ecchymosis can be found as far back as Hippocrates, Galen, and Leonardo da Vinci.[2][3][4] The association between the abdominal wall ecchymosis and intra-abdominal pathology distinguishes Grey Turner’s sign from non-specific abdominal wall ecchymosis of other causes not associated with intra-abdominal pathology such as direct trauma to the flank.

In severe acute pancreatitis, the injured pancreas releases pancreatic enzymes that cause fat necrosis and inflammation occasionally resulting in peri-pancreatic bleeding. The resulting fluid collection can travel via an anatomical defect of the transversalis fascia to the space between the 2 leaves of the renal fascia. It then flows to the pararenal space followed by the lateral edge of the quadratus lumborum muscle and finally to the subcutaneous tissue of the flanks.[5] Even in the presence of intra-abdominal or retroperitoneal hemorrhage Grey Turner’s sign may not manifest for several days. In the setting of pancreatitis, it appeared most commonly on day 3 or 4 in some older case series. One review of a case series found that subcutaneous abdominal wall signs of intra-abdominal bleeding occur more commonly in women than men with a ratio of 3:1.[6] However, no large well-controlled study exists to confirm this finding.

Clinical Significance

A careful physical examination, including visualization of the abdominal wall itself in select patients, may show a Grey Turner’s sign suggesting potentially serious intra-abdominal pathology, in particular, intra-abdominal or retroperitoneal bleeding. This may be especially important in the setting of patients who cannot provide an otherwise adequate history or demonstrate abdominal tenderness on examination due to altered mental status or intubation with mechanical ventilation. Additionally, Grey Turner’s sign may guide a clinician to consider retroperitoneal hemorrhage in unstable patients. This is particularly important in an unstable patient with a bedside ultrasound that reveals no intra-abdominal bleeding, given that ultrasonography cannot reliably detect retroperitoneal bleeding.[7] Thus, when clinicians are searching for the location of hemorrhage and a clear intra-abdominal source is not present on bedside ultrasonography, a retroperitoneal source may exist and occasionally may produce a Grey Turner's sign. Although historically associated with severe acute necrotizing pancreatitis Grey Turner’s sign is non-specific and may be present with almost any condition causing intra-abdominal or retroperitoneal bleeding including ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy, splenic rupture, ruptured hepatocellular carcinoma, perforated duodenal ulcer, bleeding intra-abdominal metastases, perirenal hemorrhage, and hemorrhagic ascites[8] among others.

Researchers have not adequately determined the sensitivity and specificity of Grey Turner’s sign in detecting intra-abdominal or retroperitoneal pathology although sensitivity is almost certainly low. Studies have shown it is an uncommon finding among patients with pancreatitis, present in about 1%.[9] Thus, the sensitivity of Grey Turner’s sign in detecting pancreatitis in general likely approaches zero. The sensitivity for detecting severe necrotizing pancreatitis, which has a higher probability of intra-abdominal bleeding, is probably somewhat higher though still too low to rule out the condition. The sensitivity of Grey Turner’s sign for other etiologies of intra-abdominal or retroperitoneal bleeding is unknown though too low to be of clinical utility to rule out pathology. The specificity likely is higher but in isolation the finding predicts only intra-abdominal pathology not any specific diagnosis. Additionally, direct trauma to the flank may cause subcutaneous findings that mimic Grey Turner’s sign but are not associated with intra-abdominal pathology (hence, a false positive Grey Turner’s sign). With these caveats, clinicians should know that when Grey Turner’s sign is present in the absence of known direct trauma to the flank, for example, a patient presenting with non-traumatic abdominal pain, it appears to be a marker of severe illness with a potentially high mortality rate. For example, in one case series 37% of patients with pancreatitis and Grey Turner’s sign succumbed to the disease.[6] Nonetheless, a finding of Grey Turner’s sign should lead to a consideration of imaging (generally computed tomography [CT]) to determine the severity of underlying pathology and to reveal unanticipated diagnoses many of which are fatal if not detected and treated early.

In addition to the physical exam finding of flank ecchymosis, CT scanning may reveal a radiographic Grey Turner’s sign. In a review of patients with severe acute pancreatitis who underwent CT imaging, researchers found that radiographic evidence of extension of retroperitoneal fluid collections laterally beyond the aponeurotic layer to the abdominal wall predicted organ failure and death with an overall mortality rate near 40%.

Other commonly cited subcutaneous manifestations of intra-abdominal or retroperitoneal hemorrhage include Cullen's sign (periumbilical ecchymosis), Fox’s sign (ecchymosis of the upper thigh with a sharply defined superior border paralleling and inferior to the inguinal ligament) and Bryant’s sign (blue discoloration of the scrotum).


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Grey-Turner Sign - Questions

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A 75-year-old man with hypertension, diabetes mellitus, and hyperlipidemia presents with severe epigastric abdominal pain for three days associated with vomiting. His lipase is found to be extremely elevated, and CT shows acute necrotizing pancreatitis. Clinicians find discoloration due to ecchymosis on his flanks. What is the name for this finding?



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An 81-year-old man presents to the emergency department with four days of epigastric abdominal pain and non-bloody vomiting. He is afebrile but has a blood pressure of 90/50 mmHg and a heart rate of 130 bpm. On examination, he has a tender upper abdomen and bilateral ecchymosis of the flanks. Which of the following is the most likely diagnosis in this setting?



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The Grey Turner sign classically refers to ecchymosis or discoloration of the flanks related to retroperitoneal bleeding from acute necrotizing pancreatitis though other conditions may cause flank ecchymosis. Which of the following best describes the test characteristics of the Grey Turner sign for detecting acute necrotizing pancreatitis?



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A 55-year-old known alcoholic arrives unconscious with a very elevated blood alcohol level. He has a blood pressure of 75/40 mmHg, a pulse of 120 bpm, and a hemoglobin of 9 g/dl. On examination, he has ecchymosis around the flanks bilaterally. A bedside ultrasound shows no visible intra-abdominal bleeding, and a chest x-ray is negative. A repeat hemoglobin shows a further drop in hemoglobin. Rectal examination shows no bleeding or melena, and there is no sign of external bleeding. A nasogastric tube shows no gastric blood. Which of the following is the most likely source for the drop in hemoglobin?

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A 65-year-old man arrives with vomiting and abdominal pain. On physical examination, there is some ecchymosis along his flanks bilaterally. He denies any known trauma. Which of the following diagnostic steps is most likely to reveal the diagnosis?



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Grey-Turner Sign - References

References

Mookadam F,Cikes M, Images in clinical medicine. Cullen's and Turner's signs. The New England journal of medicine. 2005 Sep 29     [PubMed]
Payne RL, SPONTANEOUS RUPTURE OF THE SUPERIOR AND INFERIOR EPIGASTRIC ARTERIES WITHIN THE RECTUS ABDOMINIS SHEATH. Annals of surgery. 1938 Oct     [PubMed]
COHN H,HOFFMAN W,GOLDNER MG, Spontaneous hemorrhage within the rectus sheath; report oa a case. The New England journal of medicine. 1953 Dec 31     [PubMed]
PARKER WS,CHRISTIANSEN KH, Rupture of the rectus abdominis muscle with hematoma. Archives of surgery (Chicago, Ill. : 1960). 1960 Oct     [PubMed]
Sugimoto M,Takada T,Yasuda H,Nagashima I,Amano H,Yoshida M,Miura F,Uchida T,Isaka T,Toyota N,Wada K,Takagi K,Kato K,Takeshita K, MPR-hCT imaging of the pancreatic fluid pathway to Grey-Turner's and Cullen's sign in acute pancreatitis. Hepato-gastroenterology. 2005 Sep-Oct     [PubMed]
Dickson AP,Imrie CW, The incidence and prognosis of body wall ecchymosis in acute pancreatitis. Surgery, gynecology     [PubMed]
Carnevale-Maffé G,Modesti PA, Out of the blue: the Grey-Turner's sign. Internal and emergency medicine. 2015 Apr     [PubMed]
Chauhan S,Gupta M,Sachdev A,D'Cruz S,Kaur I, Cullen's and Turner's sign associated with portal hypertension. Lancet (London, England). 2008 Jul 5     [PubMed]
Jacobs ML,Daggett WM,Civette JM,Vasu MA,Lawson DW,Warshaw AL,Nardi GL,Bartlett MK, Acute pancreatitis: analysis of factors influencing survival. Annals of surgery. 1977 Jan     [PubMed]

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