Abstract
In case of acute pancreatitis, the radiological equivalent of Grey-Turner’s sign, even in absence of its clinical appearance, can be detected by Computed Tomography (CT) as a necrotico -hemorrhagic collection in the subcutaneous space of the flank. It is correlated with a high severity of the disease.
Introduction
Subcutaneous ecchymosis, referred as Grey-Turner’s sign, in the flank and Cullen’s in the periumbilical region, although pathognomonic , are seldom observed at the clinical examination in case of acute pancreatitis (1). In particular, it is admitted that the Grey-Turner’s sign follows a hemorrhagic collection, rich in pancreatic enzymes, in the anterior pararenal space, while the
corresponding Cullen’s sign is secondary to tracking of fluids of pancreatic origin through the gastro-hepatic and falciform ligaments towards the navel (2). These signs indicate the severity of the disease.
A case , in which the Grey-Turner’s sign was absent at the clinical examination during the entire course of the disease, although it could be clearly recognized by helicalCT, has been observed and reported later.
Case Report(s)
An obese Italian woman 90 years old, 3 days after an excessively abundant meal, was admitted with severe signs of acute pancreatitis (APACHE II score=15). Both the Grey-Turner’s and Cullen’s signs were absent at the clinical examination on admission and also subsequently. A helical CT demonstrated only a swollen pancreas, but with fluid collections extending outside its capsule towards the retroperitoneum, especially on the left side,in the anterior perirenal space, the paracolic gutter and in the flank, where a large area of increased density could be observed. Fluid around the liver and the spleen, in the lesser cavity and in the Douglas pouch was present. Besides, it was found a bilateral pleural effusion, more evident on the left side. (Illustration 1 ).
Five days after, a laparotomy confirmed a severe pancreatitis , with necrosis and fluid collections inside and outside the pancreatic capsule, extending in the retroperitoneum especially towards the left flank.
A second helical CT , ten days from the admission, clearly showed a diffuse necrosis of the entire pancreatic gland, with necrotic fluid collections extending outside, in the lesser sac, and always towards the left flank with a persistent large subcutaneous hyperdense infiltration (Illustration 2).
The patient died in the 15th post operative day because of multiple organ failure.
Discussion
Our observation confirms the great value of CT for the diagnosis and staging of acute pancreatitis, demonstrating also the possible early extrapancreatic extension of the necrosis (3,4,5,6,7). For this purpose , we think that the precocious recognition of the radiological equivalent of the Grey-Turner ‘s sign is useful , even in absence of cutaneous signs and especially at the beginning of the disease, when, the pancreatic gland can demonstrate only edematous lesions.
References
1. Fox J.A. A diagnostic sign of extraperitoneal haemorrhage Br J Surg 1966; 53:193-95.
2. Bem J., Bradley E.L. Subcutaneous manifestations of severe acute pancreatitis. Pancreas 1988;16: 551-5.
3. Meyers M.A.,Feldberg M.A., Oliphant M. Grey-Turner’s sign and Cullen’s sign in acute pancreatitis. Gastrointest Radiol 1989; 14:31-7.
4. Sugimoto M.,Takada T., Yasuda H., Nagashima I. et al. MPR-hCT imaging of pancreatic fluid pathway to Grey-Turner’s and Cullen’s sign in acute pancreatitis. Hepatogastroenterology 2005; 52:1613-6.
5. De Waele J.J.,Delrue L., Hoste E.A., DE Vos M. et al. Extrapancreatic inflammation on abdominal computed tomography as an arly predictor of disease severity in acute pancreatitis. Evaluation and a new scoring system. Pancreas 2007 ;2: 185-90.
6. Delrue L.J.,De Waele J.J., Doyck Ph.O. Acute panceatitis: radiological scorse in predicting severity and outcome. Abdom. Imaging 2010; 35 : 349-61.
7. Morgan D.E. Imaging of acute pancreatituis and its complications.Clin.Gastroeneterol.Hepatol.2008;6:1077-85.
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