Subcutaneous manifestations of severe acute pancreatitis.

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Subcutaneous manifestations of severe acute pancreatitis (Grey Turner's sign, Cullen's sign, and disseminated fat necrosis) are often discussed but seldom observed. Grey Turner's sign and Cullen's sign develop in <3% of patients with acute pancreatitis; subcutaneous fat necrosis occurs even less frequently. Few younger physicians have ever seen representative cases. Only recently have studies begun to clarify the development of these clinical signs. Grey Turner's sign is produced by the spread of hemorrhagic fluid from the posterior pararenal space to the lateral edge of the quadratus lumborum muscle and, subsequently, to the subcutaneous tissues via a defect in the fascia of the flank. Cullen's sign arises from the diffusion of retroperitoneal blood into the falciform ligament and, subsequently, to the subcutaneous umbilical tissues via the connective tissue covering of the round ligament complex. In contrast to the ecchymotic signs, our review of the existing literature concerning the development of subcutaneous fat necrosis in patients with acute pancreatitis did not reveal a definitive pathogenesis. Multiple factors seem to be involved in the production of subcutaneous fat necrosis, and a simple cause-and-effect relationship of circulating lipolytic enzymes seems unlikely.