From the Guidelines
A positive Murphy sign checks for inflammation of the gallbladder, specifically acute cholecystitis. During this physical examination test, the examiner places their fingers under the patient's right rib cage and asks the patient to take a deep breath. If the patient experiences pain and abruptly stops breathing when the inflamed gallbladder touches the examiner's fingers, this indicates a positive Murphy sign. The test works because deep inspiration causes the gallbladder to descend and make contact with the examiner's hand, which creates pain when the gallbladder is inflamed. This sign is particularly useful in the clinical evaluation of right upper quadrant pain and is often accompanied by other symptoms of cholecystitis such as fever, nausea, and vomiting. While a positive Murphy sign strongly suggests gallbladder inflammation, it should be correlated with other clinical findings, laboratory tests (like elevated white blood cell count), and imaging studies (such as ultrasound) for a definitive diagnosis of acute cholecystitis, as suggested by the 2020 World Society of Emergency Surgery guidelines 1. Some key features for the diagnosis of acute cholecystitis include history and clinical examination (fever, right upper quadrant pain or tenderness, vomiting or food intolerance; Murphy’s sign), laboratory tests (elevated C-reactive protein, elevated white blood cell count), and imaging (signs suggestive of gallbladder inflammation) 1. It's also important to note that the combination of clinical signs, laboratory tests, and imaging features, such as the Tokyo Guidelines (TG) criteria, can be useful in diagnosing acute cholecystitis, although the accuracy of these criteria can vary 1. In terms of imaging, ultrasound is often the first choice for evaluating suspected acute cholecystitis, as it can detect gallstones and gallbladder inflammation with high sensitivity and specificity, as reported in a study published in the Journal of the American College of Radiology 1. Overall, a positive Murphy sign is a valuable tool in the clinical evaluation of suspected acute cholecystitis, but it should be used in conjunction with other diagnostic modalities to confirm the diagnosis. Key points to consider when evaluating a patient with a positive Murphy sign include:
- Correlating the physical examination findings with laboratory tests and imaging studies
- Considering the patient's clinical presentation and medical history
- Using a combination of diagnostic modalities, such as ultrasound and laboratory tests, to confirm the diagnosis of acute cholecystitis
- Being aware of the potential limitations and variability of the Tokyo Guidelines (TG) criteria for diagnosing acute cholecystitis 1.
From the Research
Positive Murphy Sign
- The positive Murphy sign is a useful adjunct in the assessment of patients with suspected acute cholecystitis 2.
- It is defined as the presence of maximal tenderness elicited over a sonographically localized gallbladder 2, 3.
- The sign is used to check for acute cholecystitis, and its presence can indicate the need for further evaluation or treatment.
Diagnostic Accuracy
- The overall accuracy of the sonographic Murphy sign in diagnosing acute cholecystitis is around 87% 2.
- The sensitivity of the sonographic Murphy sign is around 63-86% 2, 3, while the specificity is around 35-93% 2, 3.
- The predictive value of a positive Murphy sign is around 72-85% 2, 4, while the predictive value of a negative sign is around 82-90% 2, 3.
Combination with Other Signs
- The combination of a positive Murphy sign with other sonographic findings, such as gallstones or gallbladder wall thickening, can improve the diagnostic accuracy of acute cholecystitis 5, 4.
- The addition of laboratory tests, such as an elevated neutrophil count, can also improve the diagnostic accuracy of acute cholecystitis when combined with a positive Murphy sign and sonographic findings 4.