What is Murphy's sign, and what are the characteristics of choledochal cysts and benign biliary stricture causes?

Murphy's Sign, Choledochal Cysts, and Benign Biliary Strictures

Murphy's sign is defined as inspiratory arrest on deep palpation at the right upper quadrant (RUQ), which is characteristic of acute cholecystitis but has relatively low specificity for this condition. 1

Murphy's Sign

Murphy's sign is an important clinical finding in the evaluation of suspected biliary disease:

• It is elicited when a patient experiences pain with inspiratory arrest during deep palpation of the right upper quadrant 1
• The sonographic version is defined as tenderness reproducing the patient's abdominal pain when the ultrasound probe compresses directly on the gallbladder, combined with absence of similar tenderness when compressed elsewhere 1
• While helpful in diagnosis, Murphy's sign has relatively low specificity for acute cholecystitis and its absence is unreliable as a negative predictor if the patient has received pain medication prior to examination 1
• It is more characteristic of acute rather than chronic cholecystitis 1
• Indirect fist percussion of the liver has been shown to be more sensitive (60%) than Murphy's sign (30%) for detecting hepatobiliary infections 2

Choledochal Cysts

Choledochal cysts are congenital or acquired cystic dilatations of the intra- or extrahepatic bile ducts, classified according to the Todani system:

• Type I: Cystic dilatation of the extrahepatic biliary tree (most common, accounting for approximately 84% of cases) 3
• Type II: Isolated diverticulum protruding from the common bile duct 3
• Type III: Choledochocele (dilatation of the intraduodenal portion of the common bile duct) 3
• Type IV: Multiple cysts of both intrahepatic and extrahepatic bile ducts 3
• Type V: Single or multiple intrahepatic bile duct cysts (Caroli's disease) 3

Clinical implications of choledochal cysts:

• They can lead to complications including biliary stasis, inflammation, stricture formation, stone formation, cholangitis, pancreatitis, and malignant degeneration 4
• Complete surgical resection is recommended due to the risk of malignancy 3
• The preferred surgical approach is complete cystectomy with cholecystectomy and Roux-en-Y hepaticojejunostomy 3

Benign Biliary Strictures

The most common causes of benign biliary strictures include:

• Previous cholecystectomy (iatrogenic bile duct injury) is the most common cause 5
• Other causes include:
  • Gallstones and associated inflammation 5
  • Chronic pancreatitis 5
  • Primary sclerosing cholangitis (PSC) 5
  • Idiopathic fibrosing pancreatitis 5

Diagnostic approach for biliary strictures:

• Magnetic resonance cholangiopancreatography (MRCP) is the preferred non-invasive imaging modality 5
• Endoscopic retrograde cholangiopancreatography (ERCP) offers both diagnostic and therapeutic options 5
• Isolated benign choledochal strictures may be successfully treated with therapeutic ERCP including biliary sphincterotomy, stricture dilation, and stenting 5

Clinical Pearls and Pitfalls

• Murphy's sign should be interpreted in the context of the entire clinical picture and imaging findings, as it alone is not sufficient for diagnosis of acute cholecystitis 1, 6
• Ultrasound remains the initial test of choice for imaging patients with suspected acute cholecystitis due to its availability, lack of radiation, and ability to evaluate for alternative diagnoses 1
• Early laparoscopic cholecystectomy is the preferred treatment for acute cholecystitis and generally results in shorter recovery time and hospitalization compared to delayed approaches 1
• In patients with uncomplicated cholecystitis, if source control is complete with cholecystectomy, no postoperative antimicrobial therapy is necessary 1
• Choledochal cysts require complete surgical excision due to the risk of malignant transformation 3