Murphy sign is a bedside clinical test used to help diagnose acute cholecystitis, the sudden inflammation of the gallbladder. The examiner hooks their fingers under the right ribcage at the gallbladder’s location and asks the patient to take a deep breath; if the descending gallbladder meets those fingers and the resulting tenderness is sharp enough to make the patient catch their breath or stop inhaling, the sign is considered positive. Its pooled sensitivity sits around 59% and its specificity around 77%, which means it is a useful clue but far from a definitive one. How and when this sign helps, when it misleads, and what happens when imaging enters the picture are all worth understanding.
How the Test Is Performed
The technique sounds simple, but getting it right matters. The examiner places their hand flat on the patient’s abdomen and presses their fingertips gently upward beneath the right costal margin, roughly where the gallbladder sits. The patient is then asked to inhale deeply. As the diaphragm pushes the liver and gallbladder downward, an inflamed gallbladder comes into contact with the examiner’s fingers. If that contact provokes enough pain that the patient involuntarily halts their breath, the sign is positive.
Incorrect finger placement is one of the most common reasons the sign gives misleading results. If the examiner’s hand is too far medial, too far lateral, or not adequately hooked beneath the costal margin, the gallbladder may descend without being compressed, producing a false negative even when genuine cholecystitis is present.1Journal of Symptoms and Signs. Murphy’s sign of cholecystitis– a brief revisit This is worth knowing because any single bedside test is only as good as the hands performing it, and even experienced clinicians occasionally miss the anatomical landmark.
What Murphy Sign Actually Tells You
A pooled analysis of research on the physical exam in suspected acute cholecystitis found the Murphy sign had a sensitivity of about 59% and a specificity of about 77%.2Medicine Plus. The diagnostic accuracy of physical signs: practice experience compared with research evidence In plain terms, roughly six out of ten people with confirmed cholecystitis will test positive, and about eight out of ten people without it will correctly test negative. That makes the sign moderately helpful for raising suspicion, but not reliable enough to rule cholecystitis in or out on its own.
A systematic review in JAMA reported a positive likelihood ratio of about 2.8 for the Murphy sign, though the confidence interval was wide enough to include 1.0.3JAMA. Does This Patient Have Acute Cholecystitis? A likelihood ratio around 2.8 means a positive Murphy sign roughly triples the pre-test odds of cholecystitis, which is a meaningful bump but nowhere near conclusive on its own. A likelihood ratio whose confidence interval crosses 1.0 signals that researchers cannot be fully certain the test performs better than chance in every population studied.
One interesting finding from that same pooled analysis is that clinicians tend to overestimate how sensitive the Murphy sign is, probably because the one-to-one teaching relationship between the sign and acute cholecystitis gets emphasized in medical school.4Medicine Plus. The diagnostic accuracy of physical signs: practice experience compared with research evidence In other words, doctors are trained to associate this maneuver so tightly with gallbladder disease that they expect it to catch more cases than it actually does.
The Sonographic Murphy Sign
When most people hear “Murphy sign,” they picture the hands-on version at the bedside. But there is a second variant performed during an abdominal ultrasound, and in many emergency departments it plays a bigger role. The sonographic Murphy sign works on the same principle: instead of using fingers under the rib, the ultrasound technician or physician presses the transducer directly over the gallbladder once it has been located on the screen, and watches whether that focused pressure provokes sharp, focal tenderness.5PubMed. The sonographic diagnosis of acute gangrenous cholecystitis: importance of the Murphy sign Because the gallbladder’s position is visually confirmed in real time, the examiner knows exactly where they are pressing, which eliminates one of the bedside version’s biggest weaknesses.
A prospective study evaluating the sonographic Murphy sign in over 200 patients found an overall accuracy of about 87%, with a sensitivity of 63% and a specificity of roughly 94%.6PubMed. Prospective evaluation of the sonographic Murphy sign in suspected acute cholecystitis That specificity is the standout number: when the sonographic Murphy sign is positive, the chance that it is a false alarm is small. The researchers described it as a useful but imperfect adjunct. In a prospective study of patients undergoing laparoscopic cholecystectomy for confirmed acute cholecystitis, about 62% had a positive sonographic Murphy sign.7PubMed Central. Acute Cholecystitis is an Indication for Laparoscopic Cholecystectomy: A Prospective Study That figure reinforces the theme: a positive sonographic Murphy sign is strong evidence for cholecystitis, but a negative one does not let you walk away from the diagnosis.
How Pain Medication Blunts the Sign
Emergency departments commonly give pain relief before imaging, and this creates a real diagnostic problem. A study looking at whether analgesia affects the sonographic Murphy sign found that patients who received opioid pain medication before their ultrasound were significantly more likely to get a false-negative reading. The false-negative rate in patients given opioids was about 8% compared with 3% in those who received none. Even low doses, below a morphine equivalent of 4 mg, raised the false-negative rate to about 8%. Patients medicated within 30 minutes of the ultrasound had the highest risk of a missed diagnosis, at roughly 8.5%.8PubMed Central. The sonographic Murphy sign: does analgesia matter?
Fortunately, in that study the missed cases were still caught because clinicians maintained a high level of suspicion based on other findings. But the data highlight a real tradeoff in emergency care: treating someone’s pain is important, yet doing so before the ultrasound can mask the very tenderness the test depends on. Timing the scan relative to pain medication is something many radiology and emergency medicine departments now discuss, though there is no universal protocol.
Why the Sign Fails in Older Adults
Murphy sign becomes notably less reliable in elderly patients. A retrospective study of older adults with suspected cholecystitis found the sign’s sensitivity dropped to just 48%, with a positive predictive value of 58%. When the sign was negative, diagnostic accuracy fell to only 34%.9PubMed. Murphy’s sign, acute cholecystitis and elderly people The takeaway was blunt: in elderly patients, a positive Murphy sign is still somewhat helpful, but a negative result should be treated with real caution rather than used to dismiss the diagnosis.
Several factors contribute to this. Older adults may have altered pain perception, abdominal wall laxity that makes palpation less precise, or atypical presentations of gallbladder disease in general. The gallbladder can also be positioned differently in an older person’s body. These issues make it especially important to lean on imaging and laboratory markers rather than relying on the physical exam alone in this age group.
Diabetes and Gangrenous Cholecystitis
People with diabetes represent another group where Murphy sign can be unreliable, for a different reason. Diabetic neuropathy can dull the nerve signaling in the abdomen, meaning the gallbladder might be severely inflamed or even gangrenous without producing the sharp pain that triggers a positive Murphy sign. Research on gangrenous cholecystitis in male patients found that diabetes was associated with a roughly four-fold higher probability of the gangrenous form, and suggested that reduced nerve sensation contributed to delayed diagnosis.10Annals of Hepato-Biliary-Pancreatic Surgery. Gangrenous cholecystitis in male patients: A study of prevalence and predictive risk factors
Gangrenous cholecystitis is a more advanced and dangerous stage of gallbladder inflammation, and ironically the patients most likely to develop it are also the ones whose physical exam is most likely to be falsely reassuring. This is one of the sharpest limitations of the Murphy sign: it depends on intact pain pathways, and when those pathways are compromised, the test goes quiet even as the disease worsens.
Children and Gallbladder Disease
Cholecystitis is uncommon in children, but it does occur, and diagnosing it with the Murphy sign is even harder in younger patients. A study evaluating ultrasound findings in pediatric cholecystitis found that the Murphy sign had a sensitivity of just 6% in this population.11Journal of Surgical Research. Sensitivity and predictive value of ultrasound in pediatric cholecystitis That is essentially useless as a screening tool. The positive predictive value was better at 67%, meaning that when the sign was positive it was reasonably often correct, but it was almost never positive in the first place. In pediatric cases, other ultrasound findings like gallstones and gallbladder sludge carry far more diagnostic weight.
Conditions That Fake a Positive Murphy Sign
Not every sharp right-upper-quadrant pain that halts the patient’s breath comes from the gallbladder. Fitz-Hugh-Curtis syndrome, a complication of pelvic inflammatory disease in which adhesions form on the liver capsule, can produce right-upper-quadrant pain that worsens with breathing and triggers a convincingly positive Murphy sign. Case reports have documented patients with this condition being initially misdiagnosed with acute cholecystitis based in part on a positive Murphy sign.12PubMed Central. Positive Murphy’s Sign of Fitz-Hugh-Curtis Syndrome The syndrome is most common in younger women, a demographic where cholecystitis also occurs, which makes the diagnostic overlap particularly treacherous.
Hepatitis, liver abscess, right-sided pneumonia, and even peptic ulcer disease can also produce pain in the same area and occasionally mimic a positive Murphy sign. The broader lesson is that the sign localizes tenderness to the right upper quadrant, but it does not prove the gallbladder is the source. Imaging exists partly to answer that question.
Murphy Sign in Modern Diagnostic Guidelines
The Tokyo Guidelines, first published in 2007 and updated in 2013 and beyond, represent the most widely referenced framework for diagnosing acute cholecystitis. In these guidelines, Murphy sign is listed as one of the local inflammatory signs that raises suspicion. A patient with a positive Murphy sign (or right-upper-quadrant pain and tenderness) plus a systemic sign of inflammation such as fever or elevated white blood cell count is suspected of having acute cholecystitis.13PubMed Central. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines But the updated 2013 guidelines explicitly state that definite diagnosis requires confirmatory imaging by ultrasound, CT, or hepatobiliary scintigraphy (HIDA scan).14PubMed. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos)
A European consensus statement by the European Society for Trauma and Emergency Surgery similarly recommends the Murphy sign in conjunction with the presence of gallstones or gallbladder wall thickening as diagnostic of acute cholecystitis in the right clinical context.15European Journal of Trauma and Emergency Surgery. Surgeon-performed point-of-care ultrasound for acute cholecystitis: indications and limitations The consistent message from every major guideline is the same: Murphy sign is part of the diagnostic picture, but it is never the whole picture.
Combining Murphy Sign with Lab Work and Imaging
Because the Murphy sign alone is imperfect, clinicians typically combine it with blood tests and ultrasound findings. A regional hospital review found that when a positive Murphy sign, an elevated neutrophil count, and an ultrasound showing gallstones or signs of cholecystitis were all present together, the diagnostic triad yielded a sensitivity of 74%, specificity of 62%, a positive predictive value of 80%, and a negative predictive value of 53%.16PubMed Central. Does ultrasonography accurately diagnose acute cholecystitis? Improving diagnostic accuracy based on a review at a regional hospital Even the triad’s negative predictive value was only about coin-flip territory, which means that when all three components were negative, the patient still had close to a one-in-two chance of having cholecystitis.
When ultrasound is equivocal, the next step is often a HIDA scan, a nuclear medicine study that tracks how bile flows from the liver into the gallbladder. A HIDA scan is considered the gold standard for confirming or excluding acute cholecystitis, but it takes time. Data from a surgical conference abstract showed a median delay of about 11.5 hours between a non-diagnostic ultrasound and the HIDA scan.17SAGES. DOES SELECTIVE USE OF HEPATOBILIARY SCINTIGRAPHY (HIDA) SCAN FOR DIAGNOSIS OF ACUTE CHOLECYSTITIS, FOLLOWING EQUIVOCAL NON-DIAGNOSTIC GALLBLADDER ULTRASONOGRAPHY, AFFECT OUTCOMES That half-day wait can affect clinical decisions, which is one reason a convincingly positive Murphy sign sometimes tips the balance toward earlier surgical intervention even when imaging is borderline.
Murphy Sign as a Predictor of Surgical Difficulty
Beyond its role in diagnosis, a positive Murphy sign has turned up as a predictor of how tough the surgery will be. A study analyzing factors associated with difficult laparoscopic cholecystectomy found that a positive Murphy sign was significantly more common in patients whose operations were categorized as difficult. Other predictors in the same analysis included older age, male sex, diabetes, delayed presentation, and fever.18PubMed Central. Predictive Factors for Difficult Laparoscopic Cholecystectomies in Acute Cholecystitis This makes clinical sense: a strongly positive Murphy sign suggests more intense local inflammation, which tends to make the tissue planes around the gallbladder harder to dissect. Surgeons planning a cholecystectomy in someone with a markedly tender Murphy sign and other risk factors may prepare for a longer, more complex procedure or have a lower threshold for converting from laparoscopic to open surgery.
Where the Name Comes From
The sign is named after John Benjamin Murphy, an American surgeon practicing in Chicago in the late nineteenth and early twentieth centuries. Murphy was a prolific innovator whose contributions ranged well beyond gallbladder examination; he also pioneered techniques in vascular surgery and developed an early method for end-to-end intestinal anastomosis. The eponym stuck partly because the maneuver he described was elegantly simple and partly because Murphy was one of the most prominent surgeons of his era. Some medical educators have noted that while eponymous signs can be hard to remember, Murphy sign is one of the few that virtually every medical student learns by name, likely because the test is so frequently practiced in clinical training.
There is an old clinical pearl that the original Murphy sign involved the examiner hooking their left hand under the costal margin while standing behind the seated patient, rather than the front-facing approach used today. Whether Murphy himself consistently used one position over the other is debated in historical accounts, but the underlying principle has not changed in over a century: press on the gallbladder, ask the patient to breathe, and watch what happens.