From the Guidelines
Murphy's sign is a valuable diagnostic tool for acute cholecystitis, with a positive likelihood ratio of 2.8, as reported by Trowbridge et al. 1. To perform this test, the examiner places their fingers or hand below the right costal margin (under the rib cage) at the approximate location of the gallbladder while the patient takes a deep breath. The test is positive when the patient experiences pain and abruptly stops inhaling when the inflamed gallbladder comes in contact with the examiner's hand. This occurs because deep inspiration causes the diaphragm to push the gallbladder downward, and when the inflamed gallbladder touches the examiner's hand, it creates sharp pain that makes the patient halt their breath. A positive Murphy's sign is highly suggestive of acute cholecystitis, though it should be correlated with other clinical findings such as right upper quadrant pain, fever, and elevated white blood cell count. The physiological basis for this sign is that inflammation makes the gallbladder extremely sensitive to pressure, and the sudden pain serves as a protective mechanism to prevent further irritation of the inflamed organ. Some key points to consider when using Murphy's sign include:
- It is a physical examination technique used to diagnose acute cholecystitis
- It has a positive likelihood ratio of 2.8, as reported by Trowbridge et al. 1
- It should be correlated with other clinical findings such as right upper quadrant pain, fever, and elevated white blood cell count
- The sonographic Murphy sign has a relatively low specificity for acute cholecystitis, as noted in the study by Shea et al 1. However, the most recent and highest quality study, published in 2020 by the World Society of Emergency Surgery, suggests using a combination of detailed history, complete clinical examination, laboratory tests, and imaging investigations for the diagnosis of acute calculus cholecystitis, with Murphy's sign being a useful feature 1. In clinical practice, it is essential to consider Murphy's sign as part of a comprehensive diagnostic approach, taking into account the patient's overall clinical presentation and laboratory results, as recommended by the 2020 World Society of Emergency Surgery guidelines 1.
From the Research
Murphy's Sign
- Murphy's sign is a clinical manifestation of acute cholecystitis, characterized by severe right upper quadrant pain and a positive Murphy's sign with an elevated white blood cell count 2.
- The sonographic Murphy sign is defined as the presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder 3.
- The reported prevalence of the sonographic Murphy sign is more than 95% in patients with acute cholecystitis 3.
- However, the absence of the Murphy sign increases the possibility of gangrenous cholecystitis in patients with abdominal pain and sonographic findings of cholecystitis 3.
Diagnostic Value
- The combined use of primary and secondary sonographic signs, including the Murphy sign, led to excellent positive and negative predictive values for acute cholecystitis 4.
- The positive predictive value of the Murphy sign for patients requiring cholecystectomy was 99.0% 4.
- The negative predictive value of the combined use of primary and secondary signs to exclude acute cholecystitis was 95.0% for no stones and negative sonographic Murphy sign 4.
Clinical Implications
- Ultrasonography is typically the initial diagnostic examination in patients with suspected acute cholecystitis, and the Murphy sign is an important diagnostic criterion 2.
- The presence or absence of the Murphy sign can help guide further imaging evaluation and management of patients with suspected acute cholecystitis 4, 3.