What does a positive Murphy's sign over the gallbladder indicate?

Murphy's Sign Over the Gallbladder

A positive Murphy's sign over the gallbladder indicates acute cholecystitis and represents focal tenderness elicited when the examiner's hand (or ultrasound probe) is pressed directly over the gallbladder, causing the patient to abruptly halt inspiration due to pain. 1

Clinical Definition and Technique

Murphy's sign is a clinical examination finding where:

• The examiner palpates the right upper quadrant while the patient takes a deep breath 1
• The patient experiences sharp pain and involuntarily stops inspiration when the inflamed gallbladder descends and contacts the examiner's fingers 1
• This represents direct tenderness over a sonographically or anatomically localized gallbladder 1

Diagnostic Significance

For Acute Cholecystitis Diagnosis

When combined with gallstones on imaging, a positive Murphy's sign has a 92% positive predictive value for acute cholecystitis 1. The diagnostic accuracy improves when multiple findings are present:

• Stones + positive Murphy's sign = 92.2% positive predictive value 2
• Stones + gallbladder wall thickening (>5 mm) = 95.2% positive predictive value 1, 2
• Absence of stones + negative Murphy's sign = 95% negative predictive value for excluding acute cholecystitis 1

Sonographic Murphy's Sign

The ultrasonographic Murphy's sign is defined as maximal focal tenderness when the ultrasound probe is pushed directly against the gallbladder 1. This imaging-based version:

• Has 63% sensitivity and 93.6% specificity for acute cholecystitis 3
• Should be interpreted alongside other ultrasound findings including pericholecystic fluid, distended gallbladder, and edematous gallbladder wall 1
• Is recommended as part of the diagnostic criteria in current guidelines 1

Important Clinical Caveats

When Murphy's Sign May Be Absent or Unreliable

The absence of Murphy's sign does NOT exclude acute cholecystitis, particularly in specific high-risk scenarios:

• In gangrenous cholecystitis, Murphy's sign is positive in only 33% of cases 4
• Prior pain medication administration reduces the reliability of a negative Murphy's sign 1
• In critically ill patients, gallbladder abnormalities are common even without acute cholecystitis, limiting the sign's usefulness 1
• The sonographic Murphy's sign has relatively low specificity and should not be used in isolation 1

Clinical Context Matters

Murphy's sign should be interpreted as part of the complete clinical picture:

• Fever, right upper quadrant pain, and Murphy's sign together strongly suggest acute cholecystitis 1
• A palpable gallbladder mass with Murphy's sign suggests complicated acute cholecystitis 1
• The overall accuracy of the sonographic Murphy's sign is 87.2% when used as an adjunct finding 3

Practical Application Algorithm

When evaluating a patient with suspected acute cholecystitis:

1. Perform clinical Murphy's sign during physical examination 1
2. Order ultrasound as the initial imaging test of choice 1
3. Assess for sonographic Murphy's sign during the ultrasound examination 1
4. Combine Murphy's sign findings with presence of gallstones, wall thickening >5mm, and pericholecystic fluid for diagnosis 1
5. If Murphy's sign is absent but clinical suspicion remains high (especially for gangrenous cholecystitis), proceed with additional imaging or surgical consultation 4