Grey Turner sign

DEFINITION: Blue-red-violet or green-brown discoloration of the flanks (lateral abdominal wall) due to blood dissecting through the retroperitoneum into subcutaneous tissue.

PATHOPHYSIOLOGY: In severe acute pancreatitis, activated pancreatic enzymes (trypsin, elastase, phospholipase A2) cause autodigestion, fat necrosis, and vessel wall damage. Hemorrhagic fluid tracks along the retroperitoneal fascial planes (anterior pararenal space) to the flank. Breakdown of hemoglobin gives the color change (blue to green/yellow-brown).

KEY ASSOCIATIONS: - Acute hemorrhagic/necrotizing pancreatitis (classic board answer) - Cullen sign: periumbilical ecchymosis (blood tracking along the falciform ligament). Also seen in pancreatitis and ruptured ectopic pregnancy. - Fox sign: ecchymosis over the inguinal ligament/upper thigh. - Other causes of retroperitoneal hemorrhage: ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy, retroperitoneal bleeding from anticoagulation, trauma, renal/adrenal hemorrhage, ruptured spleen or liver, and pelvic or retroperitoneal fractures.

CLINICAL SIGNIFICANCE: - Appears late (often 24-72 hours or longer) and is uncommon (about 1-3% of pancreatitis cases). - Indicates severe disease with higher morbidity and mortality. - Pancreatitis causes: Gallstones and alcohol (most common), also hypertriglyceridemia, hypercalcemia, drugs, ERCP, scorpion sting, and autoimmune disease. Mnemonic: I GET SMASHED. - Diagnosis: Dx requires 2 of 3: epigastric pain radiating to the back, lipase/amylase >3x the upper limit of normal, and characteristic imaging findings. Lipase is more specific. CT with contrast is used for complications, such as necrosis, after 72 hours. - Complications: Hypocalcemia (fat saponification), ARDS, pseudocyst, necrosis/infection, abscess, DIC, and shock. - Management: Aggressive IV fluids (lactated Ringer's), analgesia, early enteral feeding, and ICU care for severe disease. Treat the cause (for example, ERCP for cholangitis). - Prognosis: Ranson criteria, BISAP, and APACHE II.

HIGH-YIELD TIP: On exams, flank ecchymosis plus epigastric pain radiating to the back and elevated lipase should make you think of hemorrhagic pancreatitis. If the stem describes hypotension, a pulsatile abdominal mass, and flank ecchymosis, think ruptured AAA. Named after George Grey Turner, a British surgeon, who described it in 1920.