Incidence of RUQ Tenderness in Acute Cholecystitis
Right upper quadrant (RUQ) tenderness on palpation is a cardinal clinical feature of acute cholecystitis and is present in the vast majority of patients, though specific incidence rates are not precisely quantified in current guidelines.
Clinical Presentation Framework
The clinical diagnosis of acute cholecystitis relies on a combination of local and systemic inflammatory signs, with RUQ tenderness serving as a key diagnostic component 1, 2:
- Abdominal pain in the right upper quadrant is the primary presenting symptom 1
- RUQ tenderness on palpation is listed as one of the essential local signs of inflammation required for diagnosis 2
- Murphy's sign (inspiratory arrest during deep palpation of the RUQ) is a specific form of RUQ tenderness that can be elicited both on physical examination and during ultrasound 1, 2
Diagnostic Criteria and Clinical Context
According to the Tokyo Guidelines, patients are diagnosed with acute cholecystitis when they exhibit 2:
- One local sign of inflammation: Murphy's sign, mass/pain/tenderness in RUQ
- Plus one systemic sign: fever, elevated WBC, or elevated CRP
- Confirmed by diagnostic imaging findings 2
A palpable gallbladder lump with abdominal tenderness specifically indicates complicated acute cholecystitis 1, representing more extensive disease.
Important Clinical Limitations
Murphy's Sign Has Limited Diagnostic Power
- The positive likelihood ratio for Murphy's sign is only 2.8 (95% CI 0.8-8.6), demonstrating modest diagnostic utility 3
- No single clinical sign has sufficient diagnostic power to establish or exclude acute cholecystitis 3
- Prior pain medication administration invalidates the reliability of a negative Murphy's sign, making timing of examination crucial 3
Patient-Specific Considerations
The sonographic Murphy sign has relatively low specificity and may be absent in specific populations 4, 5:
- Elderly patients
- Diabetic patients
- Immunocompromised patients
- Patients who received analgesics prior to examination 4, 5
Clinical Algorithm for Diagnosis
Given that RUQ tenderness alone is insufficient for diagnosis 3:
- Document presence of RUQ tenderness/Murphy's sign as part of clinical assessment 1, 2
- Obtain RUQ ultrasound as first-line imaging (sensitivity 75.7-88%, specificity 80-86%) 5
- If ultrasound is negative or equivocal with high clinical suspicion, proceed to hepatobiliary scintigraphy (HIDA scan) (sensitivity 96-97%, specificity 90%) 4, 5
- Consider CT with IV contrast if complications are suspected 4, 5
Key Clinical Pitfall
Over one-third of patients presenting with acute RUQ pain initially suspected to have acute cholecystitis actually have alternative diagnoses 6. Therefore, while RUQ tenderness is expected in acute cholecystitis, its presence is nonspecific and requires imaging confirmation 7, 6.