What does a positive Murphy's sign indicate and how is it managed?

From the Guidelines

A positive Murphy's sign indicates acute cholecystitis, which is inflammation of the gallbladder typically caused by gallstones obstructing the cystic duct. This clinical finding occurs when a patient experiences increased pain and involuntarily stops breathing during deep palpation of the right upper quadrant of the abdomen while taking a deep breath. Management of acute cholecystitis typically involves hospital admission, intravenous fluids, pain control with medications such as morphine or hydromorphone, and intravenous antibiotics like piperacillin-tazobactam (3.375g IV every 6 hours), ceftriaxone (1-2g IV daily) plus metronidazole (500mg IV every 8 hours), or ciprofloxacin (400mg IV every 12 hours) plus metronidazole 1.

Key Points to Consider

• Definitive treatment is usually laparoscopic cholecystectomy, ideally performed within 24-72 hours of symptom onset for uncomplicated cases 1.
• For patients who are poor surgical candidates, percutaneous cholecystostomy tube placement may be considered as a temporizing measure 1.
• Patients should fast until surgical intervention to reduce gallbladder stimulation.
• The pathophysiology involves gallstone impaction causing increased pressure, inflammation, and potential bacterial infection of the gallbladder, which explains the localized tenderness and pain with Murphy's sign.
• Early cholecystectomy is a safe treatment for acute cholecystitis and generally results in shorter recovery time and hospitalization compared to delayed cholecystectomies 1.
• Ultrasound is the investigation of choice in patients suspected of having acute cholecystitis, and it typically shows pericholecystic fluid, distended gall bladder, oedematous gallbladder wall, and gall stones, and Murphy’s sign can be elicited on ultrasound examination 1. The most recent and highest quality study, published in 2020, recommends using a combination of detailed history, complete clinical examination, laboratory tests, and imaging investigations for the diagnosis of acute calculus cholecystitis 1. In this study, the authors suggest that useful features for the diagnosis of acute cholecystitis include history and clinical examination, laboratory tests, and imaging signs suggestive of gallbladder inflammation. The study also notes that the best combination of these features is not known, and the quality of evidence is very low. However, the study provides a weak recommendation for using a combination of these features for diagnosis. Overall, the management of acute cholecystitis involves a combination of medical and surgical interventions, and the choice of treatment depends on the severity of the disease and the patient's overall health. It is essential to consider the patient's quality of life, morbidity, and mortality when making treatment decisions. In general, early cholecystectomy is recommended for patients with acute cholecystitis, as it can reduce the risk of complications and improve outcomes 1. However, the timing of surgery should be individualized based on the patient's condition and the availability of resources. In some cases, percutaneous cholecystostomy tube placement may be considered as a temporizing measure for patients who are poor surgical candidates 1. Ultimately, the goal of treatment is to reduce morbidity and mortality and improve the patient's quality of life.

From the Research

Definition and Indication of Murphy's Sign

• Murphy's sign is a clinical indication of gallbladder disease, particularly acute cholecystitis, characterized by maximal tenderness elicited over a sonographically localized gallbladder 2.
• A positive Murphy's sign is often associated with abdominal pain, elevated white blood count, and other symptoms of cholecystitis 3.

Management of Positive Murphy's Sign

• The management of a positive Murphy's sign typically involves further diagnostic evaluation, such as abdominal ultrasound, to confirm the presence of gallbladder disease 4, 5.
• If cholecystitis is diagnosed, treatment may involve cholecystectomy, which is the surgical removal of the gallbladder 3.
• In some cases, point-of-care ultrasound may be used to diagnose and manage cholecystitis, particularly in pediatric patients 5.

Diagnostic Accuracy of Murphy's Sign

• The sonographic Murphy sign has been shown to have a high predictive value for acute cholecystitis, with a positive predictive value of 72.5% and a negative predictive value of 90.5% 2.
• However, the absence of the Murphy sign does not rule out gangrenous cholecystitis, and other sonographic findings, such as pericholecystic fluid and thickening of the gallbladder wall, should also be considered 6.

Clinical Considerations

• The Murphy's sign is an important clinical indicator of gallbladder disease, but it should be used in conjunction with other diagnostic tools and clinical findings to ensure accurate diagnosis and effective management 4, 5.
• The presence or absence of the Murphy sign should be considered in the context of other sonographic and clinical findings to determine the best course of treatment for patients with suspected gallbladder disease 3, 6.