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Cullen Sign

What Is It, Causes, Symptoms, and More

Author:Georgina Tiarks

Editors:Alyssa Haag,Józia McGowan, DO,Kelsey LaFayette, DNP, ARNP, FNP-C

Illustrator:Jessica Reynolds, MS

Copyeditor:David G. Walker


What is Cullen sign?

Cullen sign is a medical term used to represent periumbilical ecchymosis (i.e., bruising around the umbilicus). It is a physical exam finding describing purple or bluish discoloration of the abdominal wall around the umbilicus. This finding may indicate intraperitoneal (i.e., inside the abdominal cavity) or retroperitoneal (i.e., behind the abdominal cavity) hemorrhage. It is named after its discoverer, Thomas Stephen Cullen, who first linked periumbilical bruising to abdominal hemorrhage. Specifically, he noted this association with ruptured ectopic pregnancy and hemorrhagic pancreatitis.

Bruising around the umbilicus.

What causes Cullen sign?

Cullen sign is caused by bleeding within or behind the peritoneum. A variety of conditions may result in hemorrhage within the abdomen. The most common cause is acute pancreatitis, which may cause both Cullen and Grey Turner signs. In contrast to Cullen sign, Grey Turner sign describes the discoloration and ecchymoses of the bilateral flanks. A patient with a ruptured ectopic pregnancy (i.e., bleeding from a fertilized egg that attaches outside the uterus) may also have a positive Cullen sign.

Gastrointestinal disorders, such as a perforated duodenal ulcer (i.e., hole in the small intestine from an ulcer), ruptured spleen, amoebic liver abscess (i.e., area of pus surrounding the liver due to an infectious organism), a ruptured common bile duct, percutaneous liver biopsy (i.e., using a needle to take a liver sample), hepatocellular carcinoma (i.e., liver cancer), and hepatic lymphoma (i.e., liver tumor), may cause bleeding within the abdomen. 

In addition, a ruptured aortic aneurysm (i.e., tear in dilated aorta) or a ruptured internal iliac artery aneurysm (i.e., tear in dilated groin artery) can hemorrhage into the abdomen to cause a positive Cullen sign. 

Other causes may include severe trauma, metastatic cancer, ovarian cysts (i.e., fluid-filled sacs on the ovary), metastatic esophageal cancer, post-radiologic intervention (i.e., complication from the image-guided procedure) or coagulopathy (i.e., bleeding disorder). 

In summary, the Cullen sign signifies bleeding within the abdomen. Further testing and imaging may be conducted to differentiate the underlying cause.

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How does pancreatitis cause Cullen sign?

Pancreatitis occurs due to inflammation of the pancreas, often caused by overactivation of the pancreatic enzymes, resulting in autodigestion. The damage to the pancreas can cause hemorrhaging into the peritoneum. Studies suggest that this hemorrhagic fluid tracks alongside the gastrohepatic and falciform ligament to the umbilicus where it pools. The blood then leads to discoloration of the abdominal wall and fatty tissue, thereby leading to a positive Cullen sign

What are the signs and symptoms of Cullen sign?

Cullen sign describes yellow, blue, or purple bruising centered around the umbilicus. There may also be associated swelling present in the abdomen. The color of the bruising can represent severity with lighter, less prominent discoloration indicating less severe bleeding and darker, purple bruising typically indicating a more severe underlying condition. Sometimes, an individual may also feel abdominal pain.

What are the most important facts to know about Cullen sign?

Cullen sign is a physical exam finding of ecchymoses, or bruising, around the umbilicus. This sign indicates either intraperitoneal or retroperitoneal hemorrhaging. Cullen sign is most commonly due to acute pancreatitis or ectopic pregnancy but can also be caused by numerous other abdominal pathologies. The discoloration may range from yellow to blue and purple, depending on the severity of the bleed.

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Related links

Pancreatitis: Pathology review
Acute pancreatitis
Complications during pregnancy: Pathology review

Resources for research and reference

Barlotta, K. S., Stack, L. B., & Knoop, K. J. (2021). Grey Turner Sign and Cullen Sign. In K. J. Knoop, L. B. Stack, A. B. Storrow, & R. J. Thurman (Eds.), The Atlas of Emergency Medicine (5th ed.). McGraw-Hill. Retrieved from accessmedicine.mhmedical.com/content.aspx?aid=1181040908

Haubrich, W. S. (2002). Cullen of Cullen’s sign. Gastroenterology, 122(2): 280. DOI: 10.1016/S0016-5085(02)80293-1

Longo, D. L. (2022). Anemia Due to Acute Blood Loss. In J. Loscalzo, A. Fauci, D. Kasper, S. Hauser, D. Longo, & J. L. Jameson (Eds.), Harrison’s Principles of Internal Medicine (21st ed.). McGraw-Hill Education. Retrieved from accessmedicine.mhmedical.com/content.aspx?aid=1190473641

Rahbour, G., Ullah, M. R., Yassin, N., & Thomas, G. P. (2012). Cullen’s sign – Case report with a review of the literature. International Journal of Surgery Case Reports, 3(5): 143–146. DOI: 10.1016/j.ijscr.2012.01.001