Grey Turner sign is ecchymosis or discoloration of the flanks occurring because of abdominal pathology. Classically it is associated with severe acute necrotizing pancreatitis often in association with Cullen’s sign (periumbilical ecchymosis) but it is not specific to that.
The color of discoloration may be green, yellow, or purple depending on the degree of red blood cell breakdown in the abdominal wall tissues. The sign may occur several days after the start of the illness.
British surgeon George Grey Turner described this in 1920 and the sign is named after him. But the sign has been mentioned by Hippocrates, Galen, and Leonardo da Vinci too.
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Clinical Significance of Grey Turner Sign
Grey Turner’s sign indicates a serious intra-abdominal pathology, especially intra-abdominal or retroperitoneal bleeding.
It is, however, an important finding in cases where adequate history is not available or the patient is unconscious.
If a patient is unstable, Grey Turner’s sign may guide a clinician to consider retroperitoneal hemorrhage even when ultrasound is negative for intra-abdominal bleeding as ultrasonography is not that reliable for bleeding. If present, the physicians should confirm or rule out the pathology.
Classically, Grey Turner sign has been associated with severe acute necrotizing pancreatitis. However, Grey Turner sign is non-specific and could be associated with any condition leading to intra-abdominal bleeding.
These include the following conditions:
- Aortic aneurysm abdomen
- Ruptured ectopic pregnancy
- Ruptured hepatocellular carcinoma
- Perforated duodenal ulcer
- Splenic rupture
- Amoebic liver abscess
- Ischemic bowel
- Rectus sheath hematoma
- Percutaneous liver biopsy
- Coronary angiography
- Bleeding intra-abdominal metastases
- Hemorrhage around kidney
- Hemorrhagic ascites
The sensitivity of Grey Turner’s sign, though not determined, is considered low.
The specificity is higher but can only point towards the presence of pathology and not any specific diagnosis.
Trauma may cause false-positive findings by causing subcutaneous bleeding as the sign is present but there would not be any intra-abdominal bleed.
But in the absence of known trauma, if a patient has direct trauma to the flank, the sign does indicate severe illness.
Therefore, if Grey Turner sign is found, it should lead to further evaluation with better imaging like Computed Tomography (CT).
There is a radiographic Grey Turner sign. In patients of severe pancreatitis who underwent CT, it was noted that the extension of retroperitoneal fluid collections laterally beyond the aponeurotic layer to the abdominal wall predicted organ failure and death.
Few other signs are also suggestive of intrabdominal bleed. These are discussed below.
Other Similar Signs
Cullen Sign
Cullen sign refers to periumbilical ecchymosis. It is named after Thomas Stephen Cullen who first described the sign in ruptured ectopic pregnancy in 1916. Like Grey Turner, Cullen sign is seen rarely and present in the same spectrum of conditions.
Both signs can be seen together in some patients.
Fox’s sign
Fox’s sign refers to an ecchymosis or bruising of the upper thigh with a sharply defined superior border parallel and just inferior to the inguinal ligament. It is rarely seen in patients with retroperitoneal bleeding. It can be seen with Grey Turner and Cullen signs. The sign is named after George Henry Fox.
Bryant’s sign
Bryant sign refers to the blue discoloration of the scrotum. It is also called blue scrotum sign of Bryant. It is also present in abdominal bleeding. Though the original sign has been described in the scrotum, the discoloration can extend to the penis too.
References
- Mookadam F, Cikes M. Images in clinical medicine. Cullen’s and Turner’s signs. N. Engl. J. Med. 2005 Sep 29;353(13):1386.
- Dickson AP, Imrie CW. The incidence and prognosis of body wall ecchymosis in acute pancreatitis. Surg Gynecol Obstet. 1984 Oct;159(4):343-7.
- Chauhan S, Gupta M, Sachdev A, D’Cruz S, Kaur I. Cullen’s and Turner’s sign associated with portal hypertension. Lancet. 2008 Jul 05;372(9632):54.