The Colon Cutoff Sign: The Internist’s Perspective on
Diagnosing Acute Pancreatitis
Anthony Sandre, MD, MSc and Ameen Patel, MB, FRCP(C), FACP
About the Authors
Anthony Sandre, MD, MSc, is a Resident Physician, Internal Medicine Residency Program, McMaster University.
Ameen Patel, MB, FRCP(C), FACP, is a Professor, Department of Medicine, McMaster University.
Corresponding Author:
Submitted: September 30, 2019. Accepted: December 4, 2019. Published: August 27, 2020. DOI: 10.22374/cjgim.v15i3.397
The colon cutoff sign is a radiographic sign often associated with a diagnosis of acute pancreatitis.
The patient highlighted in this case presented with nausea, vomiting, and abdominal discomfort
and was referred with a diagnosis of viral gastroenteritis. The abdominal radiograph demonstrated
the colon cutoff sign, but all other biochemical and imaging modalities were within normal
limits. This case highlights the importance of relying on the entire clinical assessment when
diagnosing pathology.
Le signe de coupure du côlon est un signe radiographique souvent associé à un diagnostic de
pancréatite aiguë. Le patient mis en évidence dans ce cas présentait des nausées, des vomissements
et une gêne abdominale et a été orienté vers un service de gastro-entérite virale. La radiographie
abdominale a montré le signe de coupure du côlon, mais toutes les autres modalités biochimiques
et d’imagerie étaient dans les limites normales. Ce cas souligne l’importance de sappuyer sur
lensemble de lévaluation clinique pour diagnostiquer la pathologie.
A 65-year-old male presented to our hospital for evaluation of
nausea, vomiting, and abdominal pain. The patients past medical
history was notable for alcohol abuse, peptic ulcer disease, and
coronary artery disease. Physical exam demonstrated diffuse
tenderness in the right and left upper abdominal quadrants.
Electrolytes and serum lipase were within normal limits. An
abdominal radiograph (Figure 1) demonstrated the “colon
cutoff” sign concerning for acute pancreatitis. An abdominal
ultrasound was normal. Despite diagnostic imaging suggesting
otherwise, the patient was diagnosed with viral gastroenteritis
and discharged following supportive care.
The colon cutoff sign is a radiographic sign, originally
described in abdominal radiographs, indicating the absence of gas
in the colon distal to the splenic flexure.1,2 The colon cutoff sign
represents functional paralysis of the descending colon secondary
to pancreatic inflammation. Beyond case reports, there is a paucity
of published data on the sensitivity and specificity of this sign.
One retrospective chart review reported a sensitivity of 56%.3
Specificity was not reported. Although an elevation in serum
lipase is not necessarily specific, the sensitivity and specificity
for elevation of this biomarker have been reported as 85-100%.4
The sensitivity and specificity of abdominal ultrasound for the
diagnosis of acute gallstone pancreatitis is reported as 71% and
98%, respectively.5 In this case, the colon cutoff radiographic sign
was inconsistent with a biochemical diagnosis of pancreatitis.
In the setting of an abdominal radiograph showing the colon
Canadian Journal of General Internal Medicine
Volume 15, Issue 3, 2020 43
Clinical Images
CJGIM_3_2020_175414.indd 43CJGIM_3_2020_175414.indd 43 8/25/20 4:35 PM8/25/20 4:35 PM
cutoff sign, clinicians should rule-out other intra-abdominal
pathology, including, but not limited to, viral infections, colon
cancer, inflammatory bowel disease, mesenteric ischemia, and
urinary and biliary pathology. This case illustrates the importance
of assessing all available data and placing appropriate strength
on each investigation based upon its test characteristics in the
diagnostic reasoning process.
Conflict of interest
Sources of Funding
1. Cantwell DF, Pollock A V. Radiology of acute pancreatitis. J Fac Radiol
1959;10(2):95–99. doi:10.1016/S0368-2242(59)80069-5
2. Pickhardt PJ. The colon cutoff sign. Radiology 2000;215(2):387–89.
3. Brascho DJ, Reynolds TN, Zanca P. The radiographic “colon cut-off sign” in
acute pancreatitis. Radiology 1962;79(November):763–69.
Figure 1. Abdominal radiograph demonstrating the “colon cutoff sign,
indicated with a red arrow.
Canadian Journal of General Internal Medicine
44 Volume 15, Issue 3, 2020
Sandre and Patel
CJGIM_3_2020_175414.indd 44CJGIM_3_2020_175414.indd 44 8/25/20 4:35 PM8/25/20 4:35 PM