What is the significance of a positive Murphy sign in a middle-aged adult with right upper quadrant pain, nausea, and a history of gallstones, suggestive of acute cholecystitis?

Murphy Sign in Acute Cholecystitis

A positive Murphy sign in a middle-aged adult with right upper quadrant pain, nausea, and gallstones strongly suggests acute cholecystitis and mandates immediate ultrasound imaging followed by early laparoscopic cholecystectomy within 7-10 days of symptom onset. 1

Diagnostic Significance and Limitations

Clinical Utility

• Murphy sign—defined as arrest of inspiration with pressure over the right upper quadrant—is a statistically significant predictor of acute cholecystitis when combined with laboratory findings including alkaline phosphatase, white blood cell count, and total bilirubin 2
• The positive likelihood ratio is only 2.8 (95% CI 0.8-8.6), demonstrating limited diagnostic power as a standalone test 3
• The sonographic Murphy sign has relatively low specificity and should not be relied upon exclusively for diagnosis 1, 4, 5

Critical Pitfalls to Avoid

• Prior pain medication administration invalidates the reliability of a negative Murphy sign, making timing of examination crucial 4, 3
• The sign may be absent in elderly, diabetic, or immunocompromised patients despite severe gallbladder disease 3
• Overreliance on the sonographic Murphy sign results in surprisingly low diagnostic accuracy in practice 5
• The World Society of Emergency Surgery emphasizes that no single clinical sign or laboratory test has sufficient diagnostic power to establish or exclude acute cholecystitis 3

Immediate Diagnostic Algorithm

First-Line Imaging

• Ultrasound is the investigation of choice and must be performed immediately in all patients with suspected acute cholecystitis 1
• Ultrasound has approximately 81% sensitivity and 83% specificity for acute cholecystitis, with 96% accuracy for detecting gallstones 4, 6
• Key ultrasound findings include: gallstones, distended gallbladder, edematous gallbladder wall, pericholecystic fluid, and gallstones impacted in the cystic duct 1
• Additional helpful findings include tensile fundus sign (bulging fundus from increased intraluminal pressure), wall hyperemia, mucosal ischemic changes, and pericholecystic inflammation 5

Second-Line Imaging for Equivocal Cases

• Hepatobiliary scintigraphy (HIDA scan) is the gold standard diagnostic test when ultrasound is equivocal, with 97% sensitivity and 90% specificity 4, 6
• CT abdomen with IV contrast can identify complications including gangrene, perforation, or adjacent liver parenchymal hyperemia 4
• MRCP with contrast-enhanced MRI provides comprehensive evaluation and can distinguish acute from chronic cholecystitis 4

Definitive Management

Surgical Intervention

• Early laparoscopic cholecystectomy within 7-10 days (ideally 1-3 days) of symptom onset is the definitive treatment for uncomplicated acute cholecystitis 1, 6
• Early surgery is associated with fewer composite postoperative complications (11.8% vs 34.4% for late surgery), shorter hospital stay (5.4 vs 10.0 days), and lower costs 6
• Single-shot antibiotic prophylaxis is sufficient if early intervention is performed 1

Antibiotic Therapy

• Antibiotic therapy for 2-4 days is recommended if source control is adequate, with options including amoxicillin/clavulanate, eravacycline, or tigecycline 1
• For critically ill or immunocompromised patients, use piperacillin/tazobactam or eravacycline for 4 days in immunocompetent patients and up to 7 days in immunocompromised or critically ill patients 1

Alternative Management for High-Risk Patients

• Cholecystostomy may be considered for patients with multiple comorbidities who do not show clinical improvement after antibiotic therapy, followed by 4 days of antibiotics 1
• However, percutaneous cholecystostomy is associated with higher postprocedural complications (65%) compared with laparoscopic cholecystectomy (12%) 6
• In patients older than 65 years, laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared with nonoperative management (29.3%) 6