Cullen’s sign is a medical finding observed on the abdomen that signifies a severe underlying internal pathology, often involving internal bleeding or fluid tracking. This sign is characterized by a visible change to the skin around the belly button, or umbilicus. Although it is a relatively rare occurrence, its presence acts as a significant warning sign to medical professionals, indicating a potentially life-threatening condition that requires immediate attention. The sign is not a disease itself, but rather a superficial manifestation of a deeper, more serious process occurring within the abdominal or retroperitoneal cavity.
What Cullen’s Sign Looks Like
Cullen’s sign presents as superficial edema and ecchymosis, which is bruising, immediately surrounding the umbilicus. The discoloration results from blood or hemorrhagic fluid tracking from the deep abdomen through tissue planes to reach the subcutaneous fat layer near the skin. The color of the bruising varies, but is typically bluish, purple, or even black in cases of severe bleeding.
The visual presentation is caused by the breakdown of hemoglobin from escaped red blood cells into compounds like methemalbumin, which causes the characteristic color change. Because this tracking and breakdown process takes time, the sign usually does not appear immediately after the internal event, often taking 24 to 48 hours to become visible. In cases of older bleeding, the color may shift to greenish-yellow as the bruise begins to resolve.
Primary Causes of Cullen’s Sign
The appearance of Cullen’s sign is caused by significant bleeding or the leakage of hemorrhagic fluid within the abdominal or retroperitoneal space (the area behind the abdominal lining). The most frequently cited cause is acute hemorrhagic pancreatitis, a severe inflammation where digestive enzymes erode blood vessels and tissue. These enzymes and blood leak from the pancreas and spread along the fascial planes of the abdomen.
The blood tracks an anatomical path, often moving along structures like the gastrohepatic and falciform ligaments, which connect deep abdominal structures to the umbilicus. When the fluid reaches the subcutaneous tissue near the navel, it causes the visible bruising.
While acute hemorrhagic pancreatitis is the most common cause, the sign was initially described in women with a ruptured ectopic pregnancy. In this scenario, the fertilized egg implants outside the uterus, causing the fallopian tube to rupture and leading to massive internal hemorrhage.
Other Causes
Other causes include abdominal trauma leading to splenic or liver rupture, a ruptured abdominal aortic aneurysm, and bleeding into the rectus sheath. The presence of Cullen’s sign indicates a substantial volume of blood has escaped its normal vascular boundaries.
What Recognition Means for Patient Care
The recognition of Cullen’s sign immediately signals a medical emergency, mandating rapid hospitalization and intervention due to the high risk of life-threatening internal bleeding. Medical teams must quickly stabilize the patient, involving immediate hemodynamic monitoring to assess blood pressure and heart rate for signs of shock. Large-bore intravenous access is established to facilitate fluid resuscitation and potential blood transfusions to address volume loss.
Rapid diagnostic testing is necessary to identify the source and severity of the bleeding. Laboratory blood tests often include checking levels of pancreatic enzymes like amylase and lipase, which are typically elevated in pancreatitis. Imaging studies, such as computed tomography (CT) scans or ultrasound, are quickly employed to visualize internal organs, confirm fluid presence, and locate the precise source of the hemorrhage.
The urgency of recognizing this sign is underscored by the high mortality rates associated with its underlying causes. In severe acute pancreatitis cases, the presence of Cullen’s sign is associated with a significantly higher mortality rate than in cases without the sign. Prompt identification accelerates the clinical management process, moving the patient quickly toward the definitive treatment needed to address the underlying pathology.