Diagnostic Approach to Gallbladder Disease

Definition and Clinical Application

The American College of Radiology defines Murphy sign as focal tenderness corresponding to a sonographically localized gallbladder, which helps differentiate acute cholecystitis from gallstones alone and chronic cholecystitis with gallstones 1
The World Journal of Emergency Surgery notes that Murphy sign is elicited when a patient experiences increased pain and stops breathing during deep palpation of the right upper quadrant of the abdomen during inspiration 3
The sign is considered a useful feature in the clinical examination for suspected acute cholecystitis, alongside fever, right upper quadrant pain/tenderness, vomiting, and food intolerance, as stated by the World Journal of Emergency Surgery 3

The World Journal of Emergency Surgery reports a positive likelihood ratio of 2.8 (95% CI 0.8-8.6) for acute cholecystitis, though confidence intervals include 1.0 3
The American College of Radiology states that Murphy sign has relatively low specificity for acute cholecystitis when used alone 1
The Journal of the American College of Radiology notes that administration of pain medications prior to examination invalidates the reliability of a negative Murphy sign 1

The World Journal of Emergency Surgery states that no single clinical or laboratory finding has sufficient diagnostic power to establish or exclude acute cholecystitis 3
The American College of Radiology recommends that Murphy sign should be used in combination with clinical features, laboratory tests, and imaging findings for optimal diagnosis of gallbladder disease 1
The World Journal of Emergency Surgery suggests that the combination of positive Murphy sign, elevated neutrophil count, and ultrasound showing cholelithiasis or cholecystitis yields a sensitivity of 74%, specificity of 62%, and positive predictive value of 80% 1, 2

The World Journal of Emergency Surgery notes that Murphy sign may be absent in elderly, diabetic, or immunocompromised patients despite severe gallbladder disease 4
The American College of Radiology states that complicated cholecystitis may present with similar clinical findings as uncomplicated disease, requiring additional imaging studies beyond ultrasound 1

The American College of Radiology recommends that ultrasound remains the initial test of choice for imaging patients with suspected acute cholecystitis 1
The World Journal of Emergency Surgery states that the combination of clinical, laboratory, and imaging findings provides the most accurate diagnosis of gallbladder disease 3
The World Journal of Emergency Surgery suggests that when Murphy sign is positive along with other supportive findings, early laparoscopic/open cholecystectomy (within 7-10 days of symptom onset) is recommended for uncomplicated cholecystitis 5