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In case of acute pancreatitis, the radiological equivalent of Grey-Turnerâs sign, even in absence of its clinical appearance, can be detected by Computed Tomography (CT) as a necrotico -hemorrhagic collection in the subcutaneous space of the flank. It is correlated with a high severity of the disease.
Subcutaneous ecchymosis, referred as Grey-Turnerâs sign, in the flank and Cullenâs in the periumbilical region, although pathognomonic , are seldom observed  at the clinical examination in case of acute pancreatitis (1). In   particular,  it is admitted that the Grey-Turnerâs sign follows a hemorrhagic collection, rich in pancreatic enzymes, in the anterior pararenal space, while the corresponding Cullenâs sign is secondary to  tracking of fluids of pancreatic origin through the gastro-hepatic and falciform ligaments towards the navel (2). These signs indicate the severity of the disease. A case , in which the Grey-Turnerâs sign was absent at the clinical examination during the entire course of the disease, although it could be clearly recognized by helicalCT, has been observed and reported later.
An obese Italian  woman 90 years old, 3 days after  an excessively abundant meal, was admitted with severe signs of acute pancreatitis (APACHE II score=15). Both the Grey-Turnerâs and Cullenâs signs were absent at the clinical examination on admission and also subsequently.   A helical CT demonstrated only a swollen pancreas, but   with fluid collections extending outside its capsule towards the retroperitoneum, especially on the left side,in the  anterior perirenal space, the paracolic gutter and in  the flank, where a large area of increased density could be observed. Fluid around the liver and the spleen, in the lesser cavity and in the Douglas pouch was present.   Besides, it was found a bilateral pleural effusion, more evident on the left side. (Illustration 1 ). Five days after,  a laparotomy confirmed  a severe  pancreatitis , with necrosis and fluid collections inside and outside the pancreatic capsule, extending in the retroperitoneum especially towards the left flank. A second helical CT , ten days from the admission, clearly showed a diffuse necrosis of the entire pancreatic gland, with necrotic fluid collections  extending outside, in the lesser sac, and always towards the left flank with a persistent large subcutaneous  hyperdense infiltration (Illustration 2). The patient died in the 15th post operative day because of multiple organ failure.
Our observation confirms the great value of CT for the diagnosis and staging of acute pancreatitis, demonstrating also the possible early  extrapancreatic extension of the necrosis (3,4,5,6,7). For this purpose ,  we think that the precocious  recognition of the radiological equivalent of the Grey-Turner âs sign is useful , even in absence of cutaneous signs  and especially at the beginning of the disease, when, the pancreatic gland can demonstrate only edematous lesions.
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