Cullen and Grey Turner signs in abdominal pain

A 46‐year‐old man with a history of chronic hepatitis B and alcohol misuse presented with acute abdominal pain. On physical examination, in addition to jaundice and severe pallor, he had massive ascites and ecchymoses over the periumbilical area, compatible with Cullen sign (Figure, A), and over the lateral flanks, compatible with Grey Turner sign (Figure, B). His haemoglobin level was 33 g/L (reference range, 140–160 g/L) and oesophagogastroduodenoscopy was performed but did not uncover overt bleeding. Subsequent ascitic fluid tapping revealed fresh blood and atypical cells. Computed tomography scan showed multiple nodular enhancements (Figure, C, red arrows) at both lobes of the liver with massive ascites, and contrast extravasation (Figure, C, blue arrows) with fluid density of 83 Hounsfield units at the enhanced nodule at S3, compatible with a ruptured hepatocellular cancer with haemoperitoneum. Cullen and Grey Turner signs suggest intraperitoneal or retroperitoneal haemorrhage, with pancreatitis and trauma being common causes, but are rarely associated with hepatocellular cancer.