Diagnosis and Management of Biliary Disease

Clinical Findings

Murphy's sign is an important clinical finding in the evaluation of suspected biliary disease, elicited when a patient experiences pain with inspiratory arrest during deep palpation of the right upper quadrant 1, 2
The sonographic version of Murphy's sign is defined as tenderness reproducing the patient's abdominal pain when the ultrasound probe compresses directly on the gallbladder, combined with absence of similar tenderness when compressed elsewhere 2
Murphy's sign has relatively low specificity for acute cholecystitis and its absence is unreliable as a negative predictor if the patient has received pain medication prior to examination 3, 4
Murphy's sign is more characteristic of acute rather than chronic cholecystitis 3, 4

Ultrasound remains the initial test of choice for imaging patients with suspected acute cholecystitis due to its availability, lack of radiation, and ability to evaluate for alternative diagnoses 3, 4
Early laparoscopic cholecystectomy is the preferred treatment for acute cholecystitis and generally results in shorter recovery time and hospitalization compared to delayed approaches 5
In patients with uncomplicated cholecystitis, if source control is complete with cholecystectomy, no postoperative antimicrobial therapy is necessary 5

In patients with suspected acute cholecystitis, the presence of gallstones plus a positive sonographic Murphy's sign has a positive predictive value of 92%, as reported by the American College of Gastroenterology 6
The absence of stones combined with either a normal gallbladder wall or a negative Murphy's sign has a negative predictive value of 95%, according to the American College of Gastroenterology 6

The detection of pericholecystic fluid, gallbladder distension greater than 5 cm in transverse diameter, or irregular wall architecture on ultrasound suggests early acute cholecystitis even when the gallbladder wall thickness is normal, as demonstrated in a study published in Annals of Emergency Medicine (2006) 7.
Gallstones combined with a positive sonographic Murphy’s sign confer a 92 % positive predictive value for acute cholecystitis despite the absence of wall thickening, according to research in the Journal of the American College of Radiology (2019) 8.

In cases where ultrasound findings are equivocal, hepatobiliary scintigraphy (HIDA scan) provides higher sensitivity and specificity for diagnosing acute cholecystitis than ultrasound alone, as reported by the Journal of the American College of Radiology (2019) 8.