Acute Cholecystitis Diagnosis Using Murphy's Sign

Clinical Definition and Technique

The American College of Emergency Physicians recommends that a positive Murphy's sign, which is a clinical examination finding where the examiner palpates the right upper quadrant while the patient takes a deep breath, indicates acute cholecystitis and represents focal tenderness elicited when the examiner's hand is pressed directly over the gallbladder, causing the patient to abruptly halt inspiration due to pain 1, 2
The patient experiences sharp pain and involuntarily stops inspiration when the inflamed gallbladder descends and contacts the examiner's fingers, representing direct tenderness over a sonographically or anatomically localized gallbladder 1, 2

When combined with gallstones on imaging, a positive Murphy's sign has a 92% positive predictive value for acute cholecystitis, according to the Infectious Diseases Society of America 3, 4, 5
The absence of stones and a negative Murphy's sign has a 95% negative predictive value for excluding acute cholecystitis, as recommended by the Clinical Infectious Diseases guidelines 3, 4, 5

The ultrasonographic Murphy's sign, defined as maximal focal tenderness when the ultrasound probe is pushed directly against the gallbladder, has 63% sensitivity and 93.6% specificity for acute cholecystitis, as reported by the Journal of the American College of Radiology 3, 6, 4
The American College of Radiology recommends interpreting the sonographic Murphy's sign alongside other ultrasound findings, including pericholecystic fluid, distended gallbladder, and edematous gallbladder wall 1, 2, 7

The American College of Radiology notes that prior pain medication administration reduces the reliability of a negative Murphy's sign, and the sign may be absent in gangrenous cholecystitis or critically ill patients 6, 8
The absence of Murphy's sign does not exclude acute cholecystitis, particularly in high-risk scenarios, as stated by the World Journal of Emergency Surgery 6, 8

The World Journal of Emergency Surgery recommends performing clinical Murphy's sign during physical examination and ordering ultrasound as the initial imaging test of choice, assessing for sonographic Murphy's sign, and combining findings with presence of gallstones, wall thickening, and pericholecystic fluid for diagnosis 1, 2, 6, 8