Kehr’s sign is referred pain to the left shoulder caused by diaphragmatic irritation from intraperitoneal hemorrhage. It occurs due to stimulation of the phrenic nerve by free blood or clots in contact with the diaphragm. Pain typically worsens in the supine position or when the patient lowers the head.

Pathophysiology

• Blood in the peritoneal cavity irritates the diaphragm.

• The phrenic nerve (C3–C5) transmits the pain to the left shoulder.

• Kehr’s sign is classically associated with splenic rupture but may also occur in ruptured ectopic pregnancy or other intra-abdominal hemorrhages.

• Onset can be immediate or delayed up to 48 hours after the hemorrhage.

History & symptom assessment

Ask the patient about:

• Abdominal trauma (blunt or penetrating)

• Onset, intensity, and character of abdominal and shoulder pain

• Associated symptoms: abdominal rigidity, nausea, dizziness, syncope

• Previous medical conditions or anticoagulant use that may predispose to bleeding

Physical examination

1. Vital Signs

   • Assess for hypotension, tachycardia, tachypnea, and pallor.

2. Abdominal Examination

   • Inspect for bruising, distention, or ecchymosis

   • Palpate for tenderness and rigidity

   • Percuss for Ballance’s sign: fixed dullness in the left flank (perisplenic clot) and shifting dullness in the right flank (free blood)

3. Referred Pain Assessment

   • Ask the patient to lie supine or lower the head; pain radiating to the left shoulder suggests Kehr’s sign.

Emergency interventions

• Immediate Actions

  • Elevate feet 30° if signs of hypovolemia appear

  • Establish large-bore IV access for fluid resuscitation and blood replacement

  • Insert an indwelling urinary catheter for monitoring urine output

  • Provide supplemental oxygen

  • Draw blood for hematocrit, hemoglobin, and type & crossmatch

• Abdominal Management

  • Withhold oral intake in anticipation of surgery

  • Prepare for abdominal X-ray, ultrasound, CT scan, and possibly paracentesis, peritoneal lavage, or culdocentesis

• Analgesia may be administered cautiously to control pain without masking worsening signs.

Medical causes

• Intra-abdominal hemorrhage (splenic rupture, ruptured ectopic pregnancy, traumatic liver or kidney injury)

  • Usually accompanied by intense abdominal pain, rigidity, and muscle spasm

  • History of trauma or anticoagulant use increases suspicion

Special considerations

• Surgery is often required for splenic rupture or major hemorrhage.

• Careful monitoring of hemodynamic status, urine output, and mental status is essential.

Patient counseling

• Explain the reason for monitoring and interventions

• Discuss fluid and food restrictions prior to surgery

• Educate about signs of worsening hemorrhage such as fainting, severe abdominal pain, or increased shoulder pain

Pediatric pointers

• Children may not verbalize pain; watch for rubbing the shoulder, irritability, pallor, or lethargy

• Early recognition is critical to prevent hypovolemic shock

References

1. Khan, S., Muhammad, I., Laabei, F., & Rothwell, J. (2009). An unusual presentation of non-pathological delayed splenic rupture: A case report. Cases Journal, 2, 6450.

2. Kodikara, S. (2009). Death due to hemorrhagic shock after delayed rupture of spleen: A rare phenomenon. American Journal of Forensic Medical Pathology, 30, 382–383.