Ruptured abdominal aortic aneurysm presented as Cullen’s sign and Grey Turner’s sign

A 60-year-old male with history of hypertension and atrial flutter was sent to our emergency department due to right flank pain and cold sweating. His conscious was clear without fever or abdominal pain. Hypotension (blood pressure: 73/52 mm Hg) and tachycardia (heart rate: 142 beats per minute) were detected at triage with marked cold sweating. Bruising around umbilicus (Cullen’s sign) and flanks (Grey Turner’s sign) were noted (Fig. 1). Bedside sonography showed dilated abdominal aorta (6 cm) with intramural hematoma and abdominal computed tomography angiography indicated AAA ruptured into vena cava with fistula formation and hemoretroperitoneum (Fig. 2). The patient received fluid resuscitation to maintain systolic blood pressure ranging from 80 to 100 mm Hg for hypotensive hemostasis immediately (1). Emergency blood transfusion without cross-matching with O-type packed red blood cells and airway protection with endotracheal intubation and ventilator support were all accomplished in a timely manner. The cardiovascular surgeon performed endovascular aneurysm repair (EVAR) for him 68 min later after arriving triage, and then, he was admitted to intensive care unit and successfully discharged 50 days after operation with mild weakness and numbness of the lower limbs.

Figure 1.

Bruising around the umbilicus (Cullen’s sign, blue arrow) and the flanks (Grey Turner’s sign, red arrow)

Figure 2.

Dilated abdominal aorta (6 cm, red double arrow) with intramural hematoma (Short blue arrow) and abdominal aortic aneurysm (Orange double arrow) rupture into vena cava with fistula formation (Red arrow) and hemoretroperitoneum (Long blue arrow)

Rupture of AAA is life-threatening even with prompt treatment. Even with typical symptoms and signs, ruptured AAA may be misdiagnosed as renal colic, perforated viscus, diverticulitis, gastrointestinal hemorrhage, or ischemia bowel disease with a ratio of 30%. Patients with risk factors, such as male sex, age between 65 and 80 years, Caucasian ethnicity, tobacco use, and atherosclerosis should draw our attention to this diagnosis (2).