What is Murphy's sign (sonographic sign)?

From the Guidelines

Murphy's sign is a physical examination finding used to detect inflammation of the gallbladder, particularly in cases of acute cholecystitis, and is characterized by focal tenderness corresponding to a sonographically localized gallbladder, as defined in a study from 1981 1. To perform this test, the examiner places their fingers or hand below the right costal margin (under the rib cage) on the patient's abdomen. The patient is asked to take a deep breath while the examiner maintains pressure. A positive Murphy's sign occurs when the patient experiences pain and abruptly stops inhaling as the inflamed gallbladder descends and comes into contact with the examiner's fingers. This happens because the inflammation makes the gallbladder tender to touch. The physiological basis for this sign is that during inspiration, the diaphragm pushes the abdominal organs downward, causing the inflamed gallbladder to move against the examiner's hand, eliciting pain. Some of the key points to note about Murphy's sign include:

• It is a helpful diagnostic indicator for gallbladder disease, though it should be interpreted alongside other clinical findings, laboratory tests, and imaging studies for a complete diagnosis 1.
• The sonographic Murphy sign has a relatively low specificity for acute cholecystitis, and its absence is unreliable as a negative predictor of acute cholecystitis if the patient has received pain medication prior to imaging 1.
• Ultrasound is the first-choice imaging investigation for patients with suspected acute cholecystitis, and Murphy's sign can be elicited on ultrasound examination 1.
• Clinical features such as right upper quadrant pain, fever, and leukocytosis, along with the findings from relevant imaging studies, are sufficient for diagnosis 1. The most recent and highest quality study, from 2024, recommends considering Murphy's sign as part of the clinical signs and symptoms of acute cholecystitis, along with abdominal pain, fever, and abdominal tenderness 1.

From the Research

Definition of Murphy's Sign

• Murphy's sign is a clinical sign used to diagnose acute cholecystitis, which is defined as the presence of maximal tenderness elicited by direct pressure over a sonographically localized gallbladder 2.
• The sign is typically positive in more than 95% of patients with acute cholecystitis, but its absence may indicate a more severe condition, such as gangrenous cholecystitis 2.

Clinical Presentation

• Typical symptoms of acute cholecystitis include colic-like upper abdominal pain lasting more than six hours, fever, or leukocytosis, and ultrasound gallbladder wall edema in combination with a positive Murphy sign 3.
• The Murphy sign is an important diagnostic criterion, and its presence or absence can guide further evaluation and management.

Diagnostic Criteria

• The diagnosis of acute cholecystitis is based on a combination of medical history, physical examination, abdominal ultrasound, and infection parameters in clinical chemistry 3.
• A positive Murphy sign, in combination with other diagnostic criteria, can confirm the diagnosis of acute cholecystitis.

Treatment Implications

• The treatment of choice for acute cholecystitis is early laparoscopic cholecystectomy 4, 5, 3, 6.
• The presence or absence of Murphy's sign does not directly influence the treatment approach, but it can help guide the diagnostic process and identify patients who may require more urgent attention.