From the Guidelines
Murphy's sign is a clinical diagnostic tool used to assess for acute cholecystitis, characterized by the patient's inability to inhale fully due to tenderness in the right upper quadrant upon deep palpation or inspiration. The sign is performed by placing the examiner's fingers or hand below the right costal margin in the area of the gallbladder while the patient takes a deep breath. A positive Murphy's sign is highly suggestive of acute cholecystitis, as it indicates inflammation of the gallbladder, which becomes more sensitive to pressure and causes pain when the descending diaphragm pushes it against the examiner's hand during inspiration 1.
Key Points to Consider
- The Murphy's sign is not definitive on its own and 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 more sensitive to pressure, and the deep inspiration brings the tender organ into contact with the examining hand, triggering pain that causes the patient to halt their breath.
- According to the 2020 World Society of Emergency Surgery updated guidelines, useful features for the diagnosis of acute calculus cholecystitis include Murphy’s sign, with a positive likelihood ratio of 2.8 1.
- It is essential to consider the patient's overall clinical presentation and combine the Murphy's sign with other diagnostic tools, such as laboratory tests and imaging investigations, to confirm the diagnosis of acute cholecystitis.
Diagnostic Approach
- The diagnosis of acute cholecystitis should be based on a combination of detailed history, complete clinical examination, laboratory tests, and imaging investigations 1.
- Ultrasound (US) is the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain, as it is very accurate at diagnosing or excluding gallstones and may differentiate cholelithiasis from gallbladder sludge, polyps, or masses 1.
- The sonographic Murphy sign, which is focal tenderness corresponding to a sonographically localized gallbladder, can be used to diagnose acute cholecystitis, but its specificity is relatively low and its absence is unreliable as a negative predictor of acute cholecystitis if the patient has received pain medication prior to imaging 1.
From the Research
Definition of Murphy Sign
- The Murphy sign is a clinical sign used to diagnose acute cholecystitis, which is an inflammation of the gallbladder.
- It is characterized by a sudden stop in inspiration when the gallbladder is pressed, indicating pain and tenderness in the area.
Clinical Presentation
- The Murphy sign is typically elicited during a physical examination, where the patient is asked to take a deep breath in and out while the examiner applies pressure to the right upper quadrant of the abdomen 2.
- A positive Murphy sign is indicated by a sudden stop in inspiration, which suggests that the gallbladder is inflamed and painful.
Diagnostic Evaluation
- The Murphy sign is often used in conjunction with other diagnostic tests, such as ultrasonography and hepatobiliary scintigraphy, to confirm the diagnosis of acute cholecystitis 2, 3.
- The sensitivity and specificity of the Murphy sign in diagnosing acute cholecystitis are not well established, but it is considered a useful clinical sign in the diagnosis of gallbladder disease.
Management of Acute Cholecystitis
- The management of acute cholecystitis typically involves early laparoscopic cholecystectomy, which is associated with improved patient outcomes and reduced morbidity and mortality 2, 3.
- In some cases, percutaneous cholecystostomy tube placement may be used as an alternative to surgery, particularly in patients with high operative risk 3.