Nursing care
Why Cullen and Grey Turner signs appear in severe pancreatitis
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated October 2026
Short answer
Cullen sign is bruising around the umbilicus and Grey Turner sign is bruising of the flanks. In severe pancreatitis, activated enzymes damage the gland and surrounding vessels, and haemorrhagic fluid tracks through tissue planes from the retroperitoneum to the skin. The signs are uncommon, often appear after a delay, and suggest severe disease with possible hypovolaemia.
From enzyme injury to bleeding around the pancreas
In acute pancreatitis, digestive enzymes are activated inside the pancreas instead of in the intestine. They injure pancreatic tissue and the surrounding fat, and in severe cases cause necrosis. Damaged blood vessel walls leak, and in haemorrhagic pancreatitis blood and enzyme-rich exudate collect around the gland in the retroperitoneal space, behind the abdominal lining.
The pancreas lies deep in the retroperitoneum, so this bleeding is hidden at first. The client may show only severe upper abdominal pain radiating to the back, nausea and tachycardia. Large volumes of fluid can be lost into the surrounding tissues even before any skin change, which is why vital sign trends matter more than waiting for bruising to appear.
How the blood reaches the skin
Haemorrhagic fluid spreads along fascial planes. Tracking laterally through the retroperitoneum toward the flanks produces Grey Turner sign, a blue-purple discoloration of the flank skin. Fluid that reaches the umbilical region, for example along ligaments connected to the umbilicus, produces Cullen sign, periumbilical bruising that can look like an old bruise with yellow-green edges.
Because the blood has to travel and break down before it is visible, these signs often develop a day or more after symptoms begin. They occur in only a small proportion of people with acute pancreatitis. They are not specific to pancreatitis either: other causes of retroperitoneal or intra-abdominal bleeding, such as a ruptured ectopic pregnancy or trauma, can produce similar bruising.
Why the signs change nursing priorities
Merck notes that these signs portend a poor prognosis. They imply haemorrhagic exudate and usually severe, necrotising disease, with risk of hypovolaemia, shock and organ failure. Finding them prompts a full reassessment: heart rate, blood pressure, respiratory rate, oxygen saturation, urine output, mental status and pain, compared with earlier readings to establish the trend.
Report the finding promptly with the vital sign trend, rather than documenting it as simple bruising. Expect closer monitoring, intravenous fluid resuscitation guided by the prescriber, blood tests and possibly imaging and transfer to a higher level of care. Avoid deep palpation over the area, measure fluid balance accurately and watch for breathing difficulty, which can accompany severe pancreatitis.
Other evidence of severe disease to look for
Because the bruising is late and uncommon, the nurse relies mostly on earlier indicators of severity. Persistent tachycardia, falling blood pressure, reduced urine output, rising respiratory rate, falling oxygen saturation and new confusion suggest a systemic inflammatory response or organ dysfunction. Fluid lost into the tissues around the pancreas can be large, so these signs may develop despite a modest visible fluid loss.
Laboratory trends such as rising urea, rising haematocrit from haemoconcentration, low calcium and high glucose can accompany severe pancreatitis, and the provider uses them with imaging and scoring tools to judge severity. The nurse's role is to collect results on time, recognise worsening trends and report them together with the bedside findings, so the overall picture is reviewed rather than isolated numbers.
Worked scenario: bruising on day two
A hypothetical client admitted with acute pancreatitis now has bluish discoloration over both flanks. Heart rate has risen over several hours and urine output has fallen. Options are to apply a cold pack and document bruising from the IV site, to ask whether the client has fallen, or to complete a focused assessment and notify the provider urgently.
Urgent assessment and notification is correct. Flank bruising with rising heart rate and falling urine output fits retroperitoneal haemorrhage and worsening volume status. A cold pack treats a superficial bruise, and asking about a fall delays action, though trauma history can be clarified later. The priority is circulation: recheck blood pressure, confirm IV access and report the trend.
Sources and further reading
Merck Manual Professional: Acute pancreatitis. Cullen and Grey Turner signs as extravasation of haemorrhagic exudate, occurring in under 3% of cases with poor prognosis; raised haematocrit and BUN from third-space losses; hyperglycaemia and hypocalcaemia.
NIDDK: Symptoms and causes of pancreatitis. Upper abdominal pain spreading to the back, rapid heart rate and signs that need emergency care.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our gastrointestinal practice questions are the closest set to what this page covers.
Common questions
Which sign is flank bruising and which is periumbilical?
Grey Turner sign is bruising of the flanks; Cullen sign is bruising around the umbilicus. Both reflect blood tracking from deeper tissues to the skin.
Does the absence of these signs mean pancreatitis is mild?
No. They are uncommon and appear late, so severe disease can be present without them. Severity is judged from vital signs, organ function and laboratory and imaging results.
Are Cullen and Grey Turner signs specific to pancreatitis?
No. Other causes of retroperitoneal or intra-abdominal bleeding, such as ruptured ectopic pregnancy or trauma, can produce similar bruising.