Grey Turner’s sign is an uncommon subcutaneous manifestation of intra-abdominal pathology that manifests as ecchymosis or discoloration of the flanks.[1] Classically it correlates with severe acute necrotizing pancreatitis, often in association with Cullen’s sign (periumbilical ecchymosis). It may also be present in many other conditions that result in intra-abdominal or retroperitoneal hemorrhage. The discoloration may be green, yellow, or purple depending on the degree of red blood cell (RBC) breakdown in the abdominal wall tissues and may not occur until several days into the course of an illness.

In an article published in 1920, British surgeon George Grey Turner, MBBS (1877-1951), described finding subcutaneous discoloration of the flanks in patients found to have severe pancreatitis. Referring to a patient with severe pancreatitis, he wrote, “I now noticed two large discolored areas in the loins. They were about the size of the palm of the hand, slightly raised above the surface, and of a dirty greenish color. There was a little edema, with pitting on pressure, but there was no pain or tenderness.” Since that publication, the exam finding of ecchymosis of the flank in association with intra-abdominal bleeding has carried Dr. Turner’s name. However, descriptions of non-traumatic abdominal wall ecchymosis exist as far back as Hippocrates, Galen, and Leonardo da Vinci.[2][3][4] The association between the abdominal wall ecchymosis and intra-abdominal pathology distinguishes Grey Turner’s sign from non-specific abdominal wall ecchymosis of other causes not associated with intra-abdominal pathology such as direct trauma to the flank.

In severe acute pancreatitis, the injured pancreas releases pancreatic enzymes that cause fat necrosis and inflammation, occasionally resulting in peri-pancreatic bleeding. The resulting fluid collection can travel via an anatomical defect of the transversalis fascia to the space between the two leaves of the renal fascia. It then flows to the pararenal space, followed by the lateral edge of the quadratus lumborum muscle and finally to the subcutaneous tissue of the flanks.[5] Even in the presence of intra-abdominal or retroperitoneal hemorrhage Grey Turner’s sign may not manifest for several days. In the setting of pancreatitis, it appeared most commonly on day 3 or 4 in some older case series. One review of a case series found that subcutaneous abdominal wall signs of intra-abdominal bleeding occur more commonly in women than men with a ratio of 3 to 1.[6] However, no large, well-controlled study exists to confirm this finding.

A careful physical examination, including visualization of the abdominal wall itself in select patients, may show a Grey Turner's sign suggesting potentially serious intra-abdominal pathology, in particular, intra-abdominal or retroperitoneal bleeding. This sign may be especially important in the setting of patients who cannot provide an otherwise adequate history or demonstrate abdominal tenderness on examination due to altered mental status or intubation with mechanical ventilation. Additionally, Grey Turner's sign may guide a clinician to consider retroperitoneal hemorrhage in unstable patients. This guidance is particularly important in an unstable patient with a bedside ultrasound that reveals no intra-abdominal bleeding, given that ultrasonography cannot reliably detect retroperitoneal bleeding.[7] Thus, when clinicians are searching for the location of hemorrhage and a clear intra-abdominal source is not present on bedside ultrasonography, a retroperitoneal source may exist and occasionally may produce a Grey Turner's sign. Although historically associated with severe acute necrotizing pancreatitis Grey Turner's sign is non-specific and may be present with almost any condition causing intra-abdominal or retroperitoneal bleeding, including ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy, splenic rupture, ruptured hepatocellular carcinoma, perforated duodenal ulcer, bleeding intra-abdominal metastases, perirenal hemorrhage, and hemorrhagic ascites[8] among others.

Researchers have not adequately determined the sensitivity and specificity of Grey Turner's sign for detecting intra-abdominal or retroperitoneal pathology, although sensitivity is almost certainly low. Studies have shown it is an uncommon finding among patients with pancreatitis, present in about 1%.[9] Thus, the sensitivity of Grey Turner's sign for detecting pancreatitis in general likely approaches zero. The sensitivity for detecting severe necrotizing pancreatitis, which has a higher probability of intra-abdominal bleeding, is probably somewhat higher though still too low to rule out the condition. The sensitivity of Grey Turner's sign for other etiologies of intra-abdominal or retroperitoneal bleeding is unknown though too low to be of clinical utility to rule out pathology. The specificity likely is higher, but in isolation, the finding predicts only intra-abdominal pathology, not any specific diagnosis. Additionally, direct trauma to the flank may cause subcutaneous findings that mimic Grey Turner's sign but are not associated with intra-abdominal pathology (hence, a false positive Grey Turner's sign). With these caveats, clinicians should know that when Grey Turner's sign is present in the absence of known direct trauma to the flank, for example, a patient presenting with non-traumatic abdominal pain, it appears to be a marker of severe illness with a potentially high mortality rate. For example, in one case series, 37% of patients with pancreatitis and Grey Turner's sign succumbed to the disease.[6] Nonetheless, a finding of Grey Turner's sign should lead to a consideration of imaging (generally computed tomography [CT]) to determine the severity of underlying pathology and to reveal unanticipated diagnoses, many of which are fatal if not detected and treated early.

In addition to the physical exam finding of flank ecchymosis, CT scanning may reveal a radiographic Grey Turner's sign. In a review of patients with severe acute pancreatitis who underwent CT imaging, researchers found that radiographic evidence of extension of retroperitoneal fluid collections laterally beyond the aponeurotic layer to the abdominal wall predicted organ failure and death with an overall mortality rate near 40%.

Other commonly cited subcutaneous manifestations of intra-abdominal or retroperitoneal hemorrhage include Cullen's sign (periumbilical ecchymosis), Fox's sign (ecchymosis of the upper thigh with a sharply defined superior border paralleling and inferior to the inguinal ligament), and Bryant's sign (blue discoloration of the scrotum).