From the Guidelines
A positive Murphy sign is a clinical finding characterized by sharp pain and abrupt cessation of inhalation when the inflamed gallbladder touches the examiner's fingers during inspiration, and it is a specific indicator of acute cholecystitis. To elicit this sign, the examiner places their fingers under the right costal margin (rib edge) and asks the patient to take a deep breath. The sign is specific for acute cholecystitis because the inflammation makes the gallbladder exquisitely tender to touch or pressure. When performing this examination, it's essential to compare with the left side as a control. Murphy sign is particularly useful in the initial bedside evaluation of patients with right upper quadrant pain, helping clinicians determine if gallbladder disease is likely before ordering imaging studies like ultrasound for confirmation, as recommended by recent guidelines 1. Some key points to consider when evaluating a patient with a positive Murphy sign include:
- Clinical signs and symptoms, such as abdominal pain in the right upper quadrant, fever, and abdominal tenderness 1
- The importance of early diagnosis and treatment of acute cholecystitis to prevent complications and improve outcomes 1
- The role of ultrasound as the initial imaging modality of choice for suspected acute cholecystitis 1
- The potential need for surgical intervention, such as laparoscopic cholecystectomy, in patients with acute cholecystitis 1
From the Research
Definition of Positive Murphy Sign
- A positive sonographic Murphy sign is defined as the presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder 2, 3, 4.
- This sign is considered useful in the evaluation of patients with suspected acute cholecystitis 2, 4.
Sensitivity and Specificity
- The sensitivity of the sonographic Murphy sign in acute cholecystitis was reported to be 86% with a specificity of 35% in one study 2.
- Another study found a sensitivity of 63% and a specificity of 93.6% 4.
- The combination of the Murphy sign accompanied by gallstones yielded a specificity of 77% 2.
Clinical Implications
- The sonographic Murphy sign is a helpful adjunctive finding in patients with proven acute cholecystitis who are evaluated with ultrasonography 2.
- The absence of the Murphy sign may increase the possibility of gangrenous cholecystitis in patients with abdominal pain and sonographic findings of cholecystitis 3.
- The sonographic Murphy sign is a useful, albeit imperfect, adjunct in the assessment of patients with suspected acute cholecystitis 4.