Grey Turner's sign and Cullen's sign in acute pancreatitis.

Four patients with acute pancreatitis presenting with Grey Turner's sign or Cullen's sign have been studied by computed tomography (CT). These observations help confirm the precise anatomic pathways by which the extravasated pancreatic enzymes and their effects lead to these cutaneous discolorations. Grey Turner's sign is produced by spread from the anterior pararenal space to between the two leaves of the posterior renal fascia and subsequently to the lateral edge of the quadratus lumborum muscle. Communication may be established to the posterior pararenal space and to the structures of the flank wall. The lumbar triangle, a site of anatomic weakness on the flank wall, may serve as a structural predisposition. Cullen's sign can be seen to be secondary to the tracking of liberated pancreatic enzymes to the anterior abdominal wall from the inflamed gastrohepatic ligament and across the falciform ligament. Another more direct pathway may be extension from inflammatory changes of the small mesentery or greater omentum to the round ligament, and then to properitoneal fat deep to the umbilicus.