Cullen’s sign is the appearance of irregular, bluish to purplish hemorrhagic patches around the umbilicus, sometimes extending to abdominal scars.

• Indicates retroperitoneal or intra-abdominal hemorrhage.

• Commonly associated with ruptured ectopic pregnancy, acute hemorrhagic pancreatitis, abdominal aneurysm rupture, duodenal ulcer perforation, or biliary obstruction.

• Discoloration develops gradually as blood tracks through subcutaneous tissues to the periumbilical area.

• In dark-skinned patients, detection may be difficult.

• Color evolution: bluish → greenish-yellow → yellow → resolution.

Pathophysiology

• Hemorrhage from intra-abdominal or retroperitoneal organs: Blood leaks into the peritoneal or retroperitoneal space.

• Tracking of blood along tissue planes: Blood follows fascial planes and reaches the subcutaneous tissue around the umbilicus.

• Subcutaneous extravasation: Leads to bluish discoloration visible on the skin.

• Extent and timing depend on volume of bleeding, tissue planes involved, and patient body habitus.

Examination Technique

Patient Observation

• Inspect the periumbilical area for bluish or purplish discoloration.

• Check abdominal scars or surrounding areas for similar patches.

• Note size, shape, and extent of discoloration.

Assessment Notes

• Compare with other causes of periumbilical discoloration (e.g., bruising from trauma).

• Assess hemodynamic status as Cullen’s sign indicates potentially severe hemorrhage.

Clinical Utility

• Indicator of intra-abdominal or retroperitoneal bleeding: Especially in acute settings.

• Supports diagnosis: Helps raise suspicion for conditions like hemorrhagic pancreatitis or ruptured ectopic pregnancy.

• Prognostic significance: Often associated with severe disease or high-risk complications.

Differential Diagnosis

Pediatric considerations

• Rare, but may occur in traumatic abdominal injury or ruptured congenital anomalies.

• Prompt recognition is crucial for surgical intervention.

Geriatric considerations

• May present subtly due to thinner subcutaneous tissue or comorbidities.

• Higher risk of complications from ruptured aneurysms or hemorrhagic pancreatitis.

Limitations

• Appears gradually, so may not be useful in early hemorrhage.

• Difficult to detect in dark-skinned patients.

• Not specific; must correlate with clinical presentation and imaging.

Patient counseling

• Explain that periumbilical bruising indicates serious internal bleeding.

• Emphasize urgent evaluation and possible surgical intervention.

• Educate on monitoring for associated symptoms: severe pain, dizziness, hypotension.

Conclusion

Cullen’s sign is a visible marker of intra-abdominal or retroperitoneal hemorrhage, most often associated with serious acute conditions such as hemorrhagic pancreatitis or ruptured ectopic pregnancy. Early recognition, combined with appropriate imaging and hemodynamic assessment, is critical for timely management and improved outcomes.

References

1. Cullen TS. The Significance of Umbilical Ecchymosis in Abdominal Hemorrhage. Surg Gynecol Obstet. 1918;26:433–436.

2. Bradley EL 3rd. Acute pancreatitis: A review. Curr Opin Gastroenterol. 1993;9(5):577–585.

3. Ryan GB, et al. Ectopic Pregnancy: Diagnosis and Management. Obstet Gynecol. 2006;107:104–113.

4. Sharma S, et al. Cullen’s Sign in Ruptured Aneurysm: Clinical Relevance. Ann Vasc Surg. 2010;24:1036.e7–1036.e9.

5. American College of Surgeons. Advanced Trauma Life Support (ATLS) Guidelines. 10th ed. 2020.