From the Guidelines
A positive Murphy sign after cystectomy and enterostomy without other symptoms requires close monitoring rather than immediate intervention. The management approach for such a patient should prioritize careful observation for any signs of developing complications, given that the Murphy sign alone has a relatively low specificity for acute cholecystitis 1. The patient should be observed for 24-48 hours with regular vital sign checks, complete blood count, and liver function tests to detect any abnormalities.
Key aspects of management include:
- Adequate hydration to prevent dehydration and promote recovery
- Pain control with acetaminophen 650mg every 6 hours as needed, avoiding NSAIDs that could potentially worsen renal function in a post-surgical patient
- Early ambulation to promote recovery and prevent postoperative ileus
If the patient remains asymptomatic during this observation period, conservative management is appropriate, as the positive Murphy sign may represent transient gallbladder irritation due to postoperative ileus or manipulation during surgery rather than acute cholecystitis 1. However, if fever, increasing abdominal pain, leukocytosis, or abnormal liver enzymes develop, further evaluation with abdominal ultrasound or CT scan is warranted to rule out biliary complications or intra-abdominal infection. Ultrasound, being the first choice of investigation for biliary symptoms or right upper quadrant abdominal pain, can help differentiate cholelithiasis from other gallbladder pathologies and assess for complications of cholecystitis 1.
This cautious approach balances the need to detect potential complications early while avoiding unnecessary interventions in a post-surgical patient whose clinical picture is otherwise reassuring. The decision to proceed with further diagnostic testing or intervention should be guided by the patient's clinical trajectory and the presence of specific indicators of complications, rather than the positive Murphy sign in isolation.
From the Research
Management Approach
The management approach for a patient with a positive Murphy sign after cystectomy and enterostomy, without other symptoms, involves careful consideration of the patient's overall condition and the potential causes of the positive Murphy sign.
- The Murphy sign is a clinical indicator of acute cholecystitis, but its presence alone does not necessarily confirm the diagnosis 2, 3, 4.
- In patients with a history of cystectomy and enterostomy, the Murphy sign may be positive due to other causes such as postoperative adhesions or inflammation 5.
- Ultrasonography is a useful diagnostic tool for evaluating suspected acute cholecystitis, but it may have a high false-negative rate 6.
- A combination of clinical signs, laboratory tests, and imaging studies may be necessary to accurately diagnose acute cholecystitis in these patients.
Diagnostic Considerations
When evaluating a patient with a positive Murphy sign after cystectomy and enterostomy, the following diagnostic considerations should be taken into account:
- The patient's medical history, including the type of surgery performed and any postoperative complications 5.
- The presence of other clinical signs or symptoms, such as fever, abdominal pain, or jaundice 2, 3, 4.
- Laboratory test results, including liver function tests and complete blood counts 6.
- Imaging study results, including ultrasonography and potentially other modalities such as computed tomography (CT) scans 2, 3, 4, 6.
Treatment Options
The treatment options for a patient with a positive Murphy sign after cystectomy and enterostomy will depend on the underlying cause of the sign and the patient's overall condition.