Grey-Turner’s sign following iatrogenic duodenal perforation

Description

A 45-year-old man presented with a 6-hour history of acute epigastric pain radiating to the back, following endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy and biliary stenting for obstructive jaundice secondary to choledocholithiasis.

The patient was markedly tender in the epigastrium and right flank, with the pain becoming progressively worse over the following 48 hours. A CT scan of the abdomen and pelvis was performed, revealing a normally enhancing pancreas with pockets of free air and fluid adjacent to the second part of the duodenum and in the retroperitoneum, extending to the right flank, an associated perinephric collection and extensive peritoneal fat stranding. Inflammatory markers were raised alongside a moderately elevated amylase, with a clotting screen within normal limits and stable serial haemoglobin levels. These findings were in keeping with a posterior duodenal perforation (figure 1A,B).

Figure 1.

Axial (A) and coronal (B) CT images demonstrating the retroperitoneal collection containing gas and fluid in association with the second part of the duodenum (long arrows). There is an associated perinephric collection (short arrows).

Four days post-ERCP, the patient reported discolouration on the right side of his abdomen. There was no history of trauma. On examination, there was a large area of erythema in the right flank, associated with pitting oedema of the subcutaneous tissues; no discrete mass was palpable (figure 2). Such an appearance was in keeping with the original description of Grey-Turner’s sign.¹

Figure 2.

Erythematous discolouration and pitting oedema of the right flank (Grey-Turner’s sign) manifesting 4 days after the onset of symptoms.

The patient was treated conservatively with nasogastric tube decompression, intravenous antibiotics and acid suppression therapy. The patient made a good recovery, both clinically and biochemically, with a concurrent gradual reduction in the eponymous sign over the next few days. We believe this is the first described case of Grey-Turner’s sign presenting following a duodenal perforation.

Learning points.

• Consider perforation in individuals presenting with acute abdominal pain following ERCP, in addition to acute pancreatitis.

• Grey-Turner’s sign is caused by tracking retroperitoneal inflammatory exudate and/or blood, usually associated with acute pancreatitis.