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Demarcated Truncal Jaundice: A Sign of Retroperitoneal Bile Leakage

Vivian C. McAlister, MB; and Alp Sener, MD
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From University of Western Ontario, London, Ontario N6A 5A5, Canada.

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Ann Intern Med. 2005;142(5):389. doi:10.7326/0003-4819-142-5-200503010-00021
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Grahic Jump Location
Figure 1.
Demarcation of bile staining in the flank and thigh after laparoscopic cholecystectomy, correlating with the lateral and lower insertions of the fascia of Scarpa.
Grahic Jump Location
Grahic Jump Location
Figure 2.
Demarcation of truncal bile staining after laparoscopic cholecystectomy.

The upper limit correlates with the horizontal superior attachment of the fascia of Scarpa.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Helical computed tomogram of the abdomen showing edema below the fascia of Scarpa on the right side of the abdomen in a patient with retroperitoneal bile leakage after laparoscopic cholecystectomy.
Grahic Jump Location




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Scholarship erosion
Posted on February 3, 2006
John G. Sotos
No Affiliation
Conflict of Interest: None Declared

Has the convenience of Internet searching caused the Annals to lower its standards of scholarship? A 2005 letter to the Annals (1) raises this and other questions.

In describing a new physical sign, the letter asserted that "In the 19th century, George Henry Fox is reputed to have noted bruising of the groin in hemorrhagic pancreatitis." A web site was the reference for this statement.

The first question is: Has innuendo become acceptable scholarship in the Annals?

The second, larger, question is: Why did the Annals allow the authors to reference a web site? A simple Pubmed search ("fox[au] AND pancreatitis") returns just 15 publications, one of which is a 1966 article by J. A. Fox in which he describes pancreatitic infra-inguinal ecchymoses (2). Thus, the web site, which, tellingly, did not provide references, was wrong.

Asking the Annals editors to conduct Pubmed searches and review websites goes too far, of course. However, there should have been suspicion about the citation because, had the sign actually originated in the 19th century, there would certainly be a printed publication to cite.

Another disturbing feature of the letter is its hedging language, viz.: "To the best of our knowledge, the anatomic role of the fascia of Scarpa in these clinical signs [Cullen, Grey Turner, Fox] has not been previously discussed." (Fox's 1966 article discussed Scarpa's fascia at length (2) (3).)

The scholarship of the letter's authors is not at issue here. The scholarship standard of the Annals is. It matters even for letters because, like mutations in DNA, small errors in the literature accumulate over time and could someday lead unpredictably to larger problems.

I suggest the Annals (a) should regard with suspicion all website citations, especially to websites lacking references, (b) for discoveries dating before 1999, insist on citation of printed works even if the print source is obscure (a website citation may additionally be provided), and (c) should not accept hedging language that is devoid of information content. These policies will help put authors in the proper frame of mind and will benefit Annals readers.

(1) McAlister VC, Sener A. Demarcated truncal jaundice: a sign of retroperitoneal bile leakage. Ann Int Med. 2005; 142: 389-390.

(2) Fox JA. A diagnostic sign of extraperitoneal hemorrhage. Br J Surg. 1966; 53: 193-195.

(3) Sotos JG. Cullen's and Turner's signs. N Engl J Med. (Letter. In press. To appear 2006.).

Conflict of Interest:

None declared

In reply
Posted on March 8, 2006
Bob Badgett
Annals of Internal Medicine
Conflict of Interest: None Declared

Annals currently allows references to websites as long as authors provide the URL and the date on which the URL was accessed. Our production editors check all URLs during editing and before the journal becomes publicly accessible on the Web to make sure the URLs are valid. If they are not, we ask the authors to provide an updated link or to remove the reference to the link.

We recognize that websites may contain unvetted or invalid information and that links to online material within websites (including websites of established journals) may have short shelf lives. (1-5) We think, however, that a policy of disallowing web references and links is too restrictive, and we agree with Dr. Sotos that journals do not have the resources to routinely check information on websites or to routinely monitor the status of links after publication. That said, we make the following recommendations to authors:

1) Avoid citing a website with content that in print would be considered unscholarly. 2) Avoid using an online reference if a more scholarly print reference is available. 3) Archive (preferably in a durable governmental or institutional archive) cited web pages, and, if possible, archive free material from e-journals and other web-based scholarly materials that you might cite in the future if that material is not published in a journal with an established archiving process.

We hope that these recommendations will help improve the transparency of source references and will facilitate access to similar versions of those references without undermining authors' freedom to cite sources in the scholarly areas that they presumably know best. We will routinely review these recommendations as reference standards and electronic archives evolve.

Bob Badgett Michael Berkwits Cynthia Mulrow

1. Evangelou E,Trikalinos TA,Ioannidis J. Unavailability of online supplementary scientific information from articles published in major journals.The FASEB Journal. 2005;19:1943-44.

2. Schilling LM, Kelly DP, Drake AL, Heilig LF, Hester EJ, Dellavalle RP. Digital information archiving policies in high-impact medical and scientific periodicals. JAMA 2004 Dec 8;292(22):2724-2726.

3. Crichlow R, Winbush N, Davies S. Accessibility and accuracy of web page references in 5 major medical journals. JAMA 2004 Dec 8;292(22):2723-2724.

4. Johnson KR, Hester EJ, Schilling LM, Dellavalle RP. Addressing internet reference loss. Lancet 2004 Feb 21;363(9409):660-661.

Conflict of Interest:

None declared

Icterus Marginatus
Posted on October 13, 2006
Vivian C McAlister
University of Western Ontario
Conflict of Interest: None Declared

I am grateful for the correction of our reference to Fox's sign and for Mr. JA Fox's receipt of due credit for noticing that limitation of inguinal bruising by the inferior insertion of Scarpa's fascia is associated with retroperitoneal hemorrhage.1,2 Even though the sign is well known the origin of the eponym is not. We could not locate it despite a search of textbooks and PubMed. We were blinkered by a reference to George Henry Fox on a website dedicated to medical eponyms into searching for a 19th century reference. George Henry Fox was a pioneer of medical photography and appeared to be a good candidate for the eponym but a search of his textbooks and of Index Medicus was negative.

Our observation of skin staining by retroperitoneal bile being limited by the insertion of Scarpa's fascia is compatible with JA Fox's report. The lower margins of Scarpa's fascia have been well documented but the upper and lateral insertions are less well known.3 The volume and distinctive color of bile permitted demonstration of all the borders of Scarpa's fascia which were photographed in our report of Icterus Marginatus. Knowledge of this anatomy is not only important to the recognition of several medical conditions but it is increasingly required in reconstructive surgery.4

This report not only described a novel clinical sign but also placed it within its historical context and suggested appropriate care.1 This was achieved within the journal's tight word and reference restrictions. Scholarship eroded or scholarship confined?

1.McAlister VC, Sener A. Demarcated truncal jaundice: a sign of retroperitoneal bile leakage. Ann Intern Med 2005;142(5):389.

2.Fox JA. A diagnostic sign of extraperitoneal haemorrhage. Br J Surg 1966;53:193-5.

3.Martin BF. The formation of abdomino-perineal sacs by the fasciae of Scarpa and Colles, and their clinical significance. J Anat 1984;138(Pt 4):603-16.

4.Worseg AP, Kuzbari R, Hubsch P et al. Scarpa's fascia flap: anatomic studies and clinical application.Plast Reconstr Surg 1997;99:1368 -80

Conflict of Interest:

None declared

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