Where and how is Murphy's sign (inflammation of the gallbladder) assessed in a patient with suspected acute cholecystitis?

Murphy's Sign: Location and Clinical Significance

Murphy's sign is assessed in the right upper quadrant of the abdomen during deep palpation while the patient takes a deep breath, and it indicates gallbladder inflammation when positive, though it has limited sensitivity and should never be used alone to diagnose acute cholecystitis. 1, 2

How to Elicit Murphy's Sign

Clinical Examination Technique

• Place your hand below the right costal margin in the right upper quadrant and ask the patient to take a deep breath during inspiration 1, 2
• A positive Murphy's sign occurs when the patient experiences sharp pain and abruptly stops breathing (inspiratory arrest) as the inflamed gallbladder descends and contacts your palpating hand 1, 2
• The sign specifically indicates focal tenderness corresponding to the anatomic location of the gallbladder 2

Sonographic Murphy's Sign

• Murphy's sign can also be elicited during ultrasound examination by applying pressure with the ultrasound transducer directly over the visualized gallbladder 1
• The sonographic Murphy's sign has 92.2% positive predictive value when combined with gallstones for diagnosing acute cholecystitis 3
• Sonographic Murphy's sign has 93.6% specificity but only 63% sensitivity, making it useful when positive but unreliable when negative 4

Clinical Significance and Diagnostic Value

Diagnostic Performance

• Murphy's sign has a positive likelihood ratio of only 2.8 (95% CI 0.8-8.6) for acute cholecystitis, with relatively low sensitivity of 30-33% 2, 5
• The sign has low specificity when used alone and cannot establish or exclude acute cholecystitis by itself 2
• Overreliance on Murphy's sign results in surprisingly low diagnostic accuracy in clinical practice 6

When Murphy's Sign is Most Useful

• Positive Murphy's sign combined with elevated neutrophil count and ultrasound showing cholelithiasis or cholecystitis yields 74% sensitivity, 62% specificity, and 80% positive predictive value for acute cholecystitis 2, 5
• The combination of stones plus positive sonographic Murphy's sign has 92.2% positive predictive value, and when combined with gallbladder wall thickening reaches 95.2% 3
• Patients requiring cholecystectomy have 99.0% positive predictive value when these combined findings are present 3

Critical Pitfalls and Limitations

When Murphy's Sign May Be Absent

• Elderly, diabetic, or immunocompromised patients may lack Murphy's sign despite severe gallbladder disease 2
• Prior administration of pain medications invalidates the reliability of a negative Murphy's sign 2
• Murphy's sign is relatively insensitive, so its absence does not exclude acute cholecystitis 6

Alternative Physical Examination Technique

• Indirect fist percussion of the liver has 60% sensitivity for hepatobiliary infection, significantly higher than Murphy's sign (30%) or right upper quadrant tenderness (33%) 7
• This technique involves gentle fist percussion over the liver area and may be more sensitive than Murphy's sign for detecting cholecystitis and cholangitis 7

Recommended Diagnostic Algorithm

Initial Assessment

• Assess for right upper quadrant pain, fever, nausea/vomiting, and Murphy's sign as part of the clinical presentation 1, 2
• Ultrasound is the investigation of choice for suspected acute cholecystitis, not Murphy's sign alone 1

Interpretation Strategy

• Never rely on Murphy's sign alone—no single clinical or laboratory finding has sufficient diagnostic power to establish or exclude acute cholecystitis 2
• Use the diagnostic triad: positive Murphy's sign + elevated neutrophil count + ultrasound showing cholelithiasis or acute cholecystitis features 2, 5
• Ultrasound findings to assess include: pericholecystic fluid, distended gallbladder, edematous gallbladder wall, gallstones impacted in cystic duct, and sonographic Murphy's sign 1

When Murphy's Sign is Negative

• A negative Murphy's sign has 90.5% negative predictive value when combined with absence of stones on ultrasound 3, 4
• Consider alternative diagnoses including biliary colic, acute hepatitis, pancreatitis, or cholangiopathies 6
• If clinical suspicion remains high despite negative Murphy's sign, proceed with ultrasound imaging regardless 2, 6