What is Murphy's sign?

Murphy's Sign: Definition and Clinical Significance

Murphy's sign is defined as focal tenderness elicited when a patient experiences increased pain and stops breathing during deep palpation of the right upper quadrant of the abdomen during inspiration, particularly over a sonographically localized gallbladder. 1

Clinical Definition and Examination Technique

• Murphy's sign is a physical examination finding where the patient experiences pain and respiratory arrest when the examiner's fingers are pressed beneath the right costal margin over the gallbladder as the patient takes a deep breath 1
• The sign helps differentiate acute cholecystitis from gallstones alone or chronic cholecystitis with gallstones 1
• During ultrasound examination, the sonographic Murphy's sign is defined as maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder 2

Diagnostic Value in Acute Cholecystitis

• Murphy's sign has a positive likelihood ratio of 2.8 (95% CI 0.8-8.6) for acute cholecystitis, though confidence intervals include 1.0 1
• The sensitivity of Murphy's sign in acute cholecystitis ranges from 63% to 97.2%, with specificity ranging from 35% to 93.6% across different studies 3, 4, 5
• When combined with gallstones on ultrasound, Murphy's sign has an excellent positive predictive value of 92.2% for acute cholecystitis 6
• The absence of Murphy's sign combined with absence of gallstones on ultrasound has a negative predictive value of 95% for excluding acute cholecystitis 6

Role in Diagnostic Algorithm

• No single clinical or laboratory finding, including Murphy's sign, has sufficient diagnostic power alone to establish or exclude acute cholecystitis 1
• The combination of positive Murphy's sign, elevated neutrophil count, and ultrasound showing cholelithiasis or cholecystitis yields a sensitivity of 74%, specificity of 62%, and positive predictive value of 80% 1
• Murphy's sign should be used in combination with other clinical features, laboratory tests, and imaging findings for optimal diagnosis of gallbladder disease 1

Clinical Pitfalls and Special Considerations

• Murphy's sign may be absent in elderly, diabetic, or immunocompromised patients despite severe gallbladder disease 1
• The absence of Murphy's sign in patients with other sonographic findings of cholecystitis may actually increase the possibility of gangrenous cholecystitis 2
• Administration of pain medications prior to examination invalidates the reliability of a negative Murphy's sign 1
• In one study of pathologically confirmed acute cholecystitis, Murphy's sign was absent in 10% of cases 5

Sonographic Murphy's Sign

• The sonographic Murphy's sign has been reported to have a sensitivity of 63-86% and specificity of 35-93.6% for acute cholecystitis 3, 4
• The positive predictive value ranges from 43-72.5%, while the negative predictive value ranges from 82-90.5% 3, 4
• When combined with other sonographic findings (stones, gallbladder wall edema, pericholecystic fluid), diagnostic accuracy improves significantly 6

Murphy's sign remains an important clinical finding in the evaluation of suspected acute cholecystitis, but should always be interpreted in conjunction with other clinical, laboratory, and imaging findings for optimal diagnostic accuracy.