Description

An elderly patient with known chronic obstructive airways disease presented with right upper quadrant pain. It was initially thought he had right lower lobe pneumonia and was treated accordingly. Over the course of the next couple of days, his liver function became deranged and a subsequent abdominal ultrasound suggested a diagnosis of acute cholecystitis. He was referred to the on-call surgical team where inspection of the abdomen revealed an umbilical hernia with associated yellow staining of the skin (figure 1). The patient was not systemically jaundiced. Clinically, the patient had peritonitis. An emergency diagnostic laparoscopy revealed a perforated gangrenous gallbladder with biliary peritonitis. The surgical management involved a subtotal cholecystectomy as the biliary anatomy was unclear, washout and drained.

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Figure 1

Incidental finding of umbilical bile – staining in a perforated gallbladder.

A bile-stained umbilicus was first reported in 1905 by Ransohoff1 in a patient with spontaneous common bile duct perforation. Johnston2 described the sign in a case of gallbladder perforation in 1930. Bile within the peritoneal cavity has tracked through the umbilical hernia defect and stained the skin above the hernia sac. As far as we are aware, this is the only available image of this sign in the medical literature.