An unusual cause of Cullen sign - blunt trauma and ruptured hemorrhagic pancreatic pseudocyst

Sep 28, 2026

A 48-year-old man with alcohol-related acute pancreatitis developed sudden severe abdominal pain radiating to the back after blunt left flank trauma while lifting a heavy generator. Computed tomography showed a hemorrhagic pancreatic cyst, followed by a day-three hemoglobin drop and new periumbilical ecchymosis. Repeat CT confirmed cyst rupture with hemoperitoneum, and paracentesis showed bloody ascites (SAAG 0.4). Managed conservatively with transfusion and tranexamic acid, the patient improved and was discharged stable. The periumbilical ecchymosis represented Cullen sign, typically linked to hemorrhagic pancreatitis but also seen with other intra-abdominal bleeding causes.

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Case presentation

Imaging, labs, and clinical course

Cullen sign overview

Images in clinical medicine An unusual cause of Cullen sign: blunt trauma and ruptured hemorrhagic pancreatic pseudocyst Chelsea Rui-Yan Chuah, Yoen Young Chuah Corresponding author: Yoen Young Chuah, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ping Tung Christian Hospital, Ping Tung, [Taiwan. yoenyoungchuah@gmail.com](Taiwan. yoenyoungchuah@gmail.com) [Received:](Received: 10 Sep 2025-Accepted: 25 Sep 2025-Published: 17 Oct 2025)[ 10 Sep 2025-](Received: 10 Sep 2025-Accepted: 25 Sep 2025-Published: 17 Oct 2025)[Accepted:](Received: 10 Sep 2025-Accepted: 25 Sep 2025-Published: 17 Oct 2025)[ 25 Sep 2025-](Received: 10 Sep 2025-Accepted: 25 Sep 2025-Published: 17 Oct 2025)[Published:](Received: 10 Sep 2025-Accepted: 25 Sep 2025-Published: 17 Oct 2025)[ 17 Oct 2025](Received: 10 Sep 2025-Accepted: 25 Sep 2025-Published: 17 Oct 2025) [Keywords:](Keywords: Cullen sign)[ Cullen sign](Keywords: Cullen sign), blunt trauma, pancreatic pseudocyst Funding: This work was supported by the research fund of Ping Tung Christian Hospital, Taiwan, [PS114011] . The funding body had no role in the intellectual content or writing of this manuscript. Copyright: Chelsea Rui-Yan Chuah et al. Pan African Medical Journal (ISSN: 1937-8688) . This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License ( [https://creativecommons.org/licenses/by/4.0/](https://creativecommons.org/licenses/by/4.0/)), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Cite this article: Chelsea Rui-Yan Chuah et al. An unusual cause of Cullen sign: blunt trauma and ruptured hemorrhagic pancreatic pseudocyst. Pan African Medical Journal. 2025;52(78) . 10. 11604/pamj.2025.52.78.49326 Available online at: [https://www.panafrican-med-journal.com//content/article/52/78/full](https://www.panafrican-med-journal.com//content/article/52/78/full) An unusual cause of Cullen sign: blunt trauma and ruptured hemorrhagic pancreatic pseudocyst Chelsea Rui-Yan Chuah1, Yoen Young Chuah2,3,& 1Chung-Hwa Bilingual Elementary School of Arts, Kaohsiung, Taiwan, 2 Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ping Tung Christian Hospital, Ping Tung, Taiwan, 3 Department of Nursing, Meiho University, Ping Tung, Taiwan &Corresponding author Yoen Young Chuah, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Ping Tung Christian Hospital, Ping Tung, Taiwan Image in medicine A 48-year-old man with a history of alcoholrelated acute pancreatitis presented with sudden, severe abdominal pain radiating to the back. He reported drinking six cans of beer daily (10 .7 UK alcohol units) for over 20 years. Nineteen days earlier, he sustained blunt trauma to his left flank while lifting a heavy generator. Abdominal computed tomography (CT) at another hospital revealed a hemorrhagic pancreatic cyst, and he was transferred to our institution. Laboratory tests revealed normocytic anaemia with normal amylase, lipase, and carbohydrate antigen 19-9 levels. On day three of hospitalisation, his haemoglobin dropped from 14 g/dL to 9.6 g/dL, and a periumbilical ecchymosis appeared (Panel A) . Repeat CT demonstrated rupture of the hemorrhagic pancreatic cyst with hemoperitoneum (Panel B) . Diagnostic paracentesis confirmed bloody ascitic fluid (SAAG = 0.4) . He was managed conservatively with blood transfusion and tranexamic acid, and was discharged after five days in stable condition. The periumbilical ecchymosis represents the Cullen sign, a rare clinical finding first described in 1918, caused by blood tracking from the peritoneal cavity to the umbilicus via the falciform ligament. Although classically associated with hemorrhagic pancreatitis, the Cullen sign may also be seen in ruptured ectopic pregnancy, ruptured abdominal aortic aneurysm, and hepatocellular carc

FAQs

What symptoms and timeline characterized the case?

The patient developed sudden severe abdominal pain radiating to the back after blunt left flank trauma. Nineteen days later he presented, and by day three of hospitalization his hemoglobin dropped and a periumbilical ecchymosis appeared.

How was Cullen sign identified in this patient?

The periumbilical ecchymosis represented Cullen sign, reflecting blood tracking from the peritoneal cavity to the umbilicus via the falciform ligament.

What confirmed the diagnosis of a ruptured hemorrhagic pancreatic cyst?

Repeat CT demonstrated rupture of the hemorrhagic pancreatic cyst with hemoperitoneum, and diagnostic paracentesis confirmed bloody ascitic fluid with SAAG = 0.4.

Sep 28, 2026

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