From the Guidelines
The Murphy's sign test is the primary provocative test used to assess a patient for cholecystitis. This test is a simple and effective way to evaluate patients with suspected acute cholecystitis, as it can help identify inflammation of the gallbladder. To perform this test, the examiner places their fingers or hand under the patient's right costal margin (where the gallbladder is located) and asks the patient to take a deep breath. In a positive Murphy's sign, the patient experiences pain and abruptly stops inspiration when the inflamed gallbladder contacts the examiner's fingers.
Key Points to Consider
- The Murphy's sign has moderate sensitivity and specificity for acute cholecystitis, though it may be less reliable in elderly patients or those with diabetes who might have diminished pain responses 1.
- Other diagnostic tests that should follow a positive Murphy's sign include ultrasound of the right upper quadrant, which can reveal gallstones, gallbladder wall thickening, or pericholecystic fluid.
- A study published in the Journal of the American College of Radiology in 2019 found that ultrasound is the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain, with a reported accuracy of 96% for detection of gallstones 1.
- While cholescintigraphy has a higher sensitivity and specificity for detecting acute cholecystitis, ultrasound remains the initial test of choice due to its shorter study time, morphologic evaluation, and ability to confirm the presence or absence of gallstones 1.
From the Research
Diagnostic Tests for Cholecystitis
To assess a patient for cholecystitis, several diagnostic tests can be employed. The choice of test often depends on the clinical presentation and the suspected severity of the condition.
- Ultrasonography is commonly used as the initial diagnostic examination due to its high sensitivity and specificity for detecting gallstones and gallbladder inflammation 2.
- Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) can provide additional information, especially in cases where complications are suspected 3.
- Cholescintigraphy, a nuclear medicine study, is considered the gold standard for diagnosing acute cholecystitis, particularly when other imaging modalities yield equivocal results 2, 3.
Provocative Tests
A provocative test that can be used to assess a patient for cholecystitis is the sonographic Murphy sign (SMS). This test involves applying pressure over the gallbladder area during an ultrasound examination. A positive Murphy sign, indicated by tenderness upon pressure, suggests acute cholecystitis 4.
Clinical Risk Assessment
Combining clinical parameters such as patient age, sex, leukocytosis (elevated white blood cell count), and the sonographic Murphy sign can effectively stratify patients into risk groups for acute cholecystitis 4. This approach helps in identifying patients who are at a higher risk and may require more urgent or aggressive management.
Management
The management of acute cholecystitis typically involves surgical intervention, with laparoscopic cholecystectomy being the preferred method for most patients 2, 5, 6. However, for patients who are poor surgical candidates due to high perioperative risk, percutaneous cholecystostomy tube placement can be an effective alternative 2, 3, 6.