From the Guidelines
Murphy's sign is a diagnostic tool used to detect gallbladder inflammation, characterized by the patient's experience of pain and abrupt cessation of inhalation when the inflamed gallbladder touches the examiner's fingers during a deep breath, with a sensitivity ranging from 50-97% and specificity around 79-96% for acute cholecystitis. This physical examination technique is performed by placing the examiner's fingers or hand below the right costal margin at the mid-clavicular line while the patient takes a deep breath. The descending diaphragm during inspiration pushes the inflamed gallbladder against the examiner's hand, causing pain. According to the most recent study 1, Murphy's sign is a key clinical sign in the diagnosis of acute cholecystitis, along with abdominal pain in the right upper quadrant, fever, and abdominal tenderness. It is essential to correlate a positive Murphy's sign with other clinical findings, laboratory tests, and imaging studies, such as ultrasound, for a definitive diagnosis of acute cholecystitis. The ultrasonographic Murphy's sign, as described in 1, involves tenderness reproducing the patient's abdominal pain elicited by probe compression directly on the gallbladder, combined with the absence of similar tenderness when it is compressed elsewhere.
Some key points to consider when interpreting Murphy's sign include:
- The sign may be absent in elderly patients, those with diabetes (due to neuropathy), or patients on strong pain medications.
- The sensitivity and specificity of Murphy's sign can vary, but it remains a valuable diagnostic tool when combined with other clinical and laboratory findings.
- Imaging studies, such as ultrasound, can provide additional evidence to support the diagnosis of acute cholecystitis, as described in 1.
- The management of intra-abdominal infections, including acute cholecystitis, requires a comprehensive approach that incorporates clinical signs and symptoms, laboratory tests, and imaging studies, as recommended in 1.
In clinical practice, Murphy's sign should be used in conjunction with other diagnostic tools to guide the management of patients with suspected acute cholecystitis, with the goal of reducing morbidity, mortality, and improving quality of life.
From the Research
Definition of Murphy's Sign
- Murphy's sign, also known as Murphy's maneuver, is a clinical test used to diagnose acute cholecystitis, which is inflammation of the gallbladder 2, 3, 4, 5, 6.
- The test involves pressing down on the right upper quadrant of the abdomen, specifically over the gallbladder area, while the patient takes a deep breath in and out 3, 5.
- A positive Murphy's sign is indicated by the patient experiencing severe tenderness or pain when the gallbladder area is pressed, which suggests inflammation of the gallbladder 3, 4, 5, 6.
Diagnostic Accuracy
- The sonographic Murphy sign has been shown to have an overall accuracy of 87.2% in diagnosing acute cholecystitis, with a sensitivity of 63% and specificity of 93.6% 3.
- The predictive value of a positive Murphy's sign is 72.5%, while the predictive value of a negative sign is 90.5% 3.
- When combined with other diagnostic criteria, such as laboratory tests and imaging studies, the accuracy of Murphy's sign in diagnosing acute cholecystitis can be improved 5, 6.
Clinical Implications
- Murphy's sign is a useful adjunct in the assessment of patients with suspected acute cholecystitis, but it should not be relied upon as the sole diagnostic criterion 3, 4, 5, 6.
- A thorough work-up, including laboratory tests, imaging studies, and physical examination, is necessary to confirm the diagnosis of acute cholecystitis 2, 5, 6.
- The use of bedside ultrasound, including the sonographic Murphy sign, can help improve diagnostic accuracy and guide treatment decisions in patients with suspected acute cholecystitis 5.