Murphy's Sign Assessment
No, a "bruised" feeling without significant pain upon palpation is NOT a positive Murphy's sign. A true Murphy's sign requires the patient to experience sharp pain and abruptly halt inspiration when the inflamed gallbladder descends and contacts the examiner's fingers during deep breathing 1.
What Constitutes a True Positive Murphy's Sign
The key diagnostic criterion is involuntary cessation of inspiration due to sharp pain, not merely tenderness or a "bruised" sensation 1. The clinical technique involves:
- Pressing your hand directly over the gallbladder in the right upper quadrant 1
- Asking the patient to take a deep breath 1
- Observing whether the patient abruptly stops breathing in mid-inspiration due to sharp pain 1
Diagnostic Performance and Clinical Context
The diagnostic value of Murphy's sign depends on its combination with other findings:
- When positive Murphy's sign is combined with gallstones on imaging, it has a 92% positive predictive value for acute cholecystitis 1
- When both Murphy's sign is negative AND no stones are present, there is a 95% negative predictive value for excluding acute cholecystitis 1
- The sonographic Murphy's sign (maximal focal tenderness when the ultrasound probe pushes against the gallbladder) has 63% sensitivity and 93.6% specificity 1
Critical Caveats for Your Clinical Scenario
Your finding of mild tenderness without significant pain is concerning for several reasons:
- Prior pain medication reduces the reliability of Murphy's sign assessment 1
- Murphy's sign may be absent in gangrenous cholecystitis or critically ill patients, where the absence of pain does not exclude serious pathology 1
- The absence of a classic Murphy's sign does not exclude acute cholecystitis, particularly in high-risk scenarios 1
Recommended Next Steps
Given the atypical presentation with "bruised" sensation rather than sharp pain, you should:
- Order ultrasound as the initial imaging test of choice for suspected biliary disease 2, 1
- Assess for sonographic Murphy's sign during the ultrasound examination 2
- Look for supporting imaging findings including gallstones, gallbladder wall thickening, pericholecystic fluid, and distended gallbladder 2, 1
- Consider that ultrasound has 96% accuracy for detecting gallstones and remains first-line imaging despite cholescintigraphy having higher sensitivity (97%) and specificity (90%) 2
The combination of clinical and imaging findings determines the diagnosis, not the Murphy's sign alone 1.