Murphy’s sign is a physical examination technique used to detect an inflamed gallbladder. It works by pressing into the right side of the abdomen while the patient breathes in deeply. If the patient suddenly stops breathing in because of sharp pain, the sign is positive, suggesting acute gallbladder inflammation (cholecystitis). The technique takes only a few seconds but requires correct hand placement and patient positioning to produce a reliable result.
Patient Positioning
Have the patient lie flat on their back with their arms relaxed at their sides. The abdominal muscles need to be as relaxed as possible, so ask the patient to bend their knees slightly if they seem tense. Stand on the patient’s right side, facing them. Before you begin, let the patient know what you’re about to do: you’ll be pressing gently but firmly under their ribs on the right side and asking them to take a deep breath.
Hand Placement
Place your fingers just below the edge of the right rib cage, in what’s called the right subcostal region. The original description of the technique involves curling your fingers beneath the front edge of the lowest ribs on the right side, pressing inward and slightly upward. You’re aiming for the area where the gallbladder sits, roughly where the outer edge of the rectus muscle (the vertical abdominal muscle) meets the rib margin. Press deeply enough that your fingertips hook under the costal margin, but not so aggressively that you cause pain from pressure alone.
The Breathing Maneuver
Once your fingers are positioned and pressing firmly, ask the patient to take a slow, deep breath in. As they inhale, the diaphragm pushes the liver and gallbladder downward toward your fingertips. In a healthy patient, the gallbladder slides past your fingers without significant discomfort, and they complete the breath normally.
If the gallbladder is inflamed, something different happens. As the diaphragm forces the swollen gallbladder down onto your examining fingers, the patient feels a sudden, sharp pain that causes them to catch their breath mid-inhale. This abrupt halt in breathing is called “inspiratory arrest,” and it’s the hallmark of a positive Murphy’s sign.
What Makes the Result Positive
A positive Murphy’s sign has two components that must both be present. First, the patient stops their deep breath because of pain when you palpate the right upper quadrant. Second, the same maneuver performed on the left side (under the left rib cage) does not produce the same response. This comparison matters. If pressing under both sides of the rib cage causes equal pain, the finding is nonspecific and doesn’t point to the gallbladder in particular.
The sign is negative if the patient completes the full deep breath without catching or wincing, or if any tenderness you find is no greater over the gallbladder area than in surrounding regions.
Why It Works
The gallbladder sits just beneath the liver, tucked under the right rib cage. Normally it’s protected from your examining hand by the ribs above it. When the patient breathes in deeply, the diaphragm contracts and pushes the liver (and the gallbladder attached to it) downward, out from under the ribs and directly into your waiting fingertips. A healthy gallbladder tolerates this contact. An inflamed one, swollen and tender from infection or a trapped gallstone, does not. The sudden contact between your fingers and the sensitive organ produces pain sharp enough that the patient reflexively stops breathing in.
How Accurate Is Murphy’s Sign
Murphy’s sign is most useful when it’s positive. It’s a fairly specific indicator of gallbladder inflammation, meaning that when it’s present, the chance of a false alarm is relatively low. However, its sensitivity is limited. A negative result does not rule out cholecystitis. Some patients with genuine gallbladder inflammation won’t demonstrate the sign, particularly elderly patients, those on pain medication, or those with a high pain tolerance.
There’s also a version performed during an abdominal ultrasound, called the sonographic Murphy sign. Instead of pressing with your fingers, the ultrasound technician or physician presses with the transducer directly over the gallbladder, which they can see on the screen in real time. This removes the guesswork about whether your fingers are actually over the gallbladder. The sonographic version has a specificity around 91%, meaning it’s quite reliable when positive, though its sensitivity sits closer to 41%, reinforcing that a negative result doesn’t clear the diagnosis.
Conditions That Can Mimic a Positive Result
Several other conditions can cause pain in the right upper quadrant during deep breathing, potentially producing a false positive. An enlarged or inflamed liver with a swollen capsule can cause similar tenderness. Peritonitis, where the lining of the abdomen is broadly inflamed, can make the entire area painful to palpation. Right-sided kidney infections and lower lobe pneumonia can also cause right upper quadrant pain that worsens with deep breathing.
This is why the comparison with the left side is important, and why Murphy’s sign is always interpreted alongside other information: the patient’s symptoms, blood work, and imaging. A positive Murphy’s sign raises suspicion of cholecystitis but doesn’t confirm it on its own.
Common Mistakes to Avoid
The most frequent error is not pressing deeply enough. If your fingers aren’t firmly hooked under the costal margin, the descending gallbladder won’t make meaningful contact with your hand, and you’ll miss a positive finding. Another common mistake is pressing too hard before asking the patient to breathe, which causes generalized pain unrelated to the gallbladder and makes the result uninterpretable.
Asking the patient to breathe too quickly is another pitfall. A slow, steady inhalation gives the gallbladder time to descend gradually into your fingers. A quick gasp doesn’t produce the same controlled contact. Finally, forgetting to repeat the maneuver on the left side as a control means you can’t distinguish gallbladder-specific pain from more widespread abdominal tenderness.