Series Editor: Herbert l. Fred, MD

Prepared by Vijay P. Balasubramanian, MD, Assistant Professor of Medicine, UCSF Fresno, Fresno, Calif, and James P. Maloney, MD, Associate Professor of Medicine, University of Colorado Health Sciences Center, Denver, Colo

A 65-year-old woman presented with abdominal pain. Physical examination showed abdominal distension, ascites, and epigastric tenderness. Serum lipase value was 2594 U/L and ionized calcium concentration was 0.5 mg/dL. Two days after admission, periumbilical bruising appeared (Figure). Computed tomography scan of the abdomen revealed extensive pancreatic edema without evidence of hemorrhage. After institution of hypertriglyceridemia therapy and 7 weeks of supportive care, the pancreatitis resolved. The periumbilical bruising lasted for 2 weeks.

Ecchymotic discoloration of the abdominal wall near the midline, from the umbilicus to the symphysis pubis, is known as Cullen’s sign. It results from retroperitoneal or intraperitoneal bleeding, with blood reaching the abdominal wall by way of the falciform and round ligaments. First described by Thomas Cullen in 1918 in association with ectopic pregnancy, this sign occurs only in 1% to 2% of patients with acute pancreatitis.

Points to remember: In the absence of trauma or blood disorders, the appearance of Cullen’s sign is a valuable bedside clue to retroperitoneal or intraperitoneal hemorrhage.

Diagnosis: Acute pancreatitis with intraperitoneal hemorrhage.