How do you manually check for cholelithiasis (gallstones)?

Manual Examination Techniques for Cholelithiasis

The most effective manual examination technique for cholelithiasis is the assessment of Murphy's sign, where direct pressure on the right upper quadrant during inspiration elicits pain and respiratory arrest, which has a positive predictive value of 92% when combined with ultrasound findings of gallstones. 1

Primary Physical Examination Techniques

Murphy's Sign

• Apply deep palpation with fingertips to the right upper quadrant just below the costal margin
• Ask the patient to take a deep breath
• Positive sign: Patient experiences pain and abruptly stops inspiration
• This occurs because the inflamed gallbladder descends and contacts the examining fingers during inspiration

Right Upper Quadrant Palpation

• Examine for tenderness in the right upper quadrant
• Note that abdominal tenderness may limit a thorough examination 1
• Document location, severity, and radiation of pain
• Assess for guarding or rigidity which may indicate peritoneal inflammation

Collins' Sign

• Ask the patient to demonstrate where they feel pain
• Positive sign: Patient places hand behind their back with thumb pointing upwards to indicate pain at the tip of the scapula
• This sign was present in 51.5% of patients with cholelithiasis compared to only 7.5% of controls, making it a useful discriminator 2

Secondary Assessment Findings

Referred Pain Patterns

• Check for pain referred to the right shoulder or right supraclavicular region 3
• This referred pain is characteristic of gallbladder disease

Associated Symptoms

• Assess for associated nausea and vomiting, which frequently accompany cholelithiasis 3
• Document timing of pain in relation to meals (typically 30-60 minutes after eating) 4

Pitfalls in Manual Examination

1. False Negatives: Lack of physical examination findings does not rule out cholelithiasis 3

   • Up to 50-70% of patients with gallstones may be asymptomatic at diagnosis 5

2. Technical Limitations: Manual examination may be limited by:

   • Obesity
   • Significant abdominal tenderness
   • Bowel gas 1

3. Misidentification: The gallbladder may be confused with other structures during examination:

   • Portal vein
   • Inferior vena cava
   • Hepatic or renal cysts 1

4. Concurrent Conditions: The presence of gallstones does not rule out other serious causes of epigastric pain:

   • Aortic aneurysm
   • Myocardial infarction 1

When to Proceed to Imaging

Manual examination alone is insufficient for definitive diagnosis. Proceed to imaging when:

• Murphy's sign is positive
• Patient reports characteristic biliary colic
• Right upper quadrant pain persists despite normal physical examination

Ultrasonography is the initial imaging test of choice with:

• 81-88% sensitivity and 80-83% specificity for gallstone disease 6
• Ability to detect thickened gallbladder wall (>3mm), pericholecystic fluid, and gallbladder distention 6

Conclusion

While manual examination techniques can help identify suspected cholelithiasis, they should be considered preliminary assessments that guide the decision to proceed with definitive imaging studies. The combination of a positive Murphy's sign and characteristic pain patterns provides the strongest clinical indication of gallstone disease, but ultrasonography remains the gold standard for diagnosis.