Collins Sign: A Clinical Indicator for Cholelithiasis
Collins sign is a clinical maneuver where patients with gallstone pain demonstrate their referred scapular pain by placing their hand behind their back with the thumb pointing upwards, serving as a useful discriminator for cholelithiasis with a positive predictive value of 51.5% in symptomatic patients.
Definition and Clinical Technique
- Collins sign was first described by Professor Paddy Collins as a characteristic gesture performed by patients experiencing gallstone-related pain 1
- The patient places their hand behind their back with the thumb pointing upward to indicate the location of referred pain at the tip of the scapula 1
- This physical demonstration reflects the typical radiation pattern of biliary colic pain from the right upper quadrant to the scapular region 1
Diagnostic Performance
Validation Study Results
- In a case-control study of 202 patients with symptomatic cholelithiasis versus 200 controls (with esophagitis, gastritis, or duodenal ulcer), Collins sign demonstrated significant diagnostic utility 1
- Sensitivity: 51.5% in patients with confirmed gallstones 1
- Specificity: 92.5% (positive in only 7.5% of control patients) 1
- The difference between groups was highly statistically significant (P < 0.001) 1
Clinical Interpretation
- A positive Collins sign is more useful for ruling in cholelithiasis than ruling it out, given its high specificity but moderate sensitivity 1
- The sign is present in approximately half of all patients with symptomatic gallstones, making it a valuable but not definitive clinical indicator 1
- When positive, it substantially increases the likelihood of cholelithiasis as the cause of right upper quadrant pain 1
Integration into Diagnostic Approach
Clinical Context
- The American College of Radiology recommends considering multiple clinical indicators when evaluating right upper quadrant pain, including characteristic pain patterns, nausea, vomiting, anorexia, and fever 2
- Collins sign should be assessed as part of the clinical examination for suspected biliary disease 2, 1
Imaging Confirmation
- Ultrasound remains the first-line imaging modality for suspected biliary disease presenting with right upper quadrant pain, with 96% accuracy for detecting gallstones 2
- A positive Collins sign should prompt ultrasound evaluation to confirm the diagnosis of cholelithiasis 2
- Abdominal imaging is recommended when the diagnosis remains uncertain after clinical examination 2
Common Pitfalls and Caveats
- Do not rely on Collins sign alone for diagnosis—it is a supplementary clinical finding that must be confirmed with imaging 2, 1
- The sign's moderate sensitivity (51.5%) means that its absence does not exclude cholelithiasis 1
- Other causes of right upper quadrant pain (peptic ulcer disease, gastritis, esophagitis) rarely produce a positive Collins sign, but overlap can occur in 7.5% of cases 1
- The sign is most useful when positive in the appropriate clinical context of right upper quadrant pain with typical biliary colic characteristics 1
Note: Collins sign should not be confused with Treacher Collins syndrome, which is an unrelated autosomal dominant genetic disorder affecting craniofacial development 3, 4, 5, 6, 7.