Clinical Practice and Cases in Emergency Medicine

Introduction: Cullen sign is an area of periumbilical ecchymosis that results from blood tracking along the round ligament. Any source of retroperitoneal or abdominal hemorrhage can cause Cullen sign, but it is often described in association with acute pancreatitis.

Case Report: Here we report a case of a chronically ill male who presented with a bulging sensation in his lower abdomen and lower abdominal pain. On physical examination this patient was noted to have a large area of periumbilical ecchymosis predominantly on the left aspect of the umbilicus, consistent with Cullen sign. Computed tomography abdomen and pelvis were remarkable for an enlarging left external iliac artery aneurysm with adjacent hematoma and multifocal intraperitoneal hematoma tracking into the right side of the abdomen, concerning for aneurysmal rupture. The patient was taken to the operating room for a left iliac artery arteriogram and stent placement.

Conclusion: Isolated iliac artery aneurysms are rare and represent less than 2% of all abdominal aneurysmal disease; furthermore, external iliac artery aneurysms are exceedingly rare and account for the least common abdominal aneurysmal pathology. This case demonstrates the importance of considering other etiologies of Cullen sign beyond pancreatitis, including aneurysmal ruptures.