When a patient presents with abdominal discomfort, clinicians rely on a variety of physical examination techniques to help pinpoint the source of the pain. These maneuvers are designed to localize tenderness and reproduce symptoms in a specific way that relates to an underlying organ or disease process. The physical assessment of the abdomen, which includes inspection, listening, and gentle touch, is a foundational step in narrowing the broad possibilities of internal causes. A positive Murphy’s Sign is one such physical clue, focusing on the right upper quadrant to guide the diagnostic process.
Defining Murphy’s Sign: The Examination Technique
Murphy’s Sign is elicited through a focused examination of the abdomen’s upper right area, specifically where the liver’s edge meets the lower ribs. The patient is asked to lie flat, and the clinician gently places their hand beneath the rib cage, targeting the approximate location of the hepatic margin. This maneuver is performed to place the examiner’s fingers directly over the area where an inflamed organ would descend during breathing.
The patient is then instructed to take a slow, deep breath while the clinician maintains firm, steady pressure in the right upper quadrant. Normally, a person can complete this deep inspiration without a sudden interruption due to localized pain. A positive sign is recorded only if the patient experiences a sharp, sudden increase in pain that causes an involuntary, abrupt stop in their breathing.
This sudden arrest of inspiration is the defining characteristic of a positive Murphy’s Sign, differentiating it from generalized tenderness or simple discomfort. The involuntary cessation of breath, often described as a “catch” in the breath, signifies a reflexive reaction to the intense pain. This reaction is a specific, localized finding that provides a strong initial hypothesis for the cause of the patient’s symptoms.
The Primary Indication: Acute Cholecystitis
The primary significance of a positive Murphy’s Sign is its strong association with acute cholecystitis, the sudden inflammation of the gallbladder. This condition is most often triggered when a gallstone obstructs the cystic duct, trapping bile inside. The blockage leads to increased pressure and irritation of the gallbladder wall.
The pathophysiology behind the positive sign is anatomical and mechanical. When the patient inhales deeply, the diaphragm contracts and pushes the liver and all structures beneath it, including the tender, inflamed gallbladder, downward. The descending organ then makes direct, forceful contact with the examiner’s firmly placed fingers.
The resulting sudden pain is due to the stimulation of hypersensitive pain receptors in the inflamed gallbladder wall, irritated by trapped bile and inflammatory mediators like prostaglandins. This sharp pain triggers the involuntary inspiratory arrest, confirming the positive sign. While the sign is a powerful clinical indicator, the diagnosis of acute cholecystitis relies on this physical finding combined with the patient’s symptoms and subsequent laboratory results.
Related Conditions and Diagnostic Challenges
While highly suggestive, a positive Murphy’s Sign is not an absolute confirmation of acute cholecystitis, nor does a negative sign completely rule it out. The diagnostic accuracy of the maneuver varies, and clinicians must consider several factors that can limit its reliability. For instance, elderly patients may exhibit a false negative result because diminished pain perception can make the characteristic inspiratory arrest less pronounced or absent.
Similarly, a patient who has received strong pain medication before the examination may present with a false negative sign, as the medication can mask the sharp tenderness necessary to elicit the involuntary reaction. Other conditions cause pain in the right upper quadrant, requiring careful differentiation. Pain from conditions such as hepatitis, a kidney infection (pyelonephritis), or a peptic ulcer can mimic cholecystitis symptoms, but typically do not cause the specific inspiratory arrest when the maneuver is performed.
The presence of the sign helps distinguish acute cholecystitis from these other possibilities, but an atypical presentation can pose a diagnostic challenge. In rare cases of severe or gangrenous cholecystitis, local nerve endings can be destroyed, resulting in a negative sign despite life-threatening inflammation. Therefore, the sign is interpreted as a piece of evidence within a larger clinical picture, not as a stand-alone diagnosis.
Subsequent Steps After a Positive Finding
A positive Murphy’s Sign, coupled with symptoms like fever and right upper quadrant pain, prompts an immediate medical pathway for confirmation and treatment. The next step involves laboratory tests to check for signs of infection and inflammation, such as an elevated white blood cell count. These tests provide systemic evidence supporting the localized physical finding.
Abdominal ultrasound is the preferred initial imaging test used to confirm acute cholecystitis. The ultrasound allows the clinician to visualize the gallbladder directly, looking for key features such as gallstones. Confirmatory findings include thickening of the gallbladder wall (typically measuring more than three millimeters) and the presence of fluid around the organ, known as pericholecystic fluid.
A variation called the sonographic Murphy’s Sign is often performed, where the ultrasound probe is used to apply pressure directly over the visually localized gallbladder to reproduce the pain. Once acute cholecystitis is confirmed, the standard definitive treatment is a cholecystectomy, the surgical removal of the gallbladder. This procedure is typically performed laparoscopically and is ideally completed within 24 to 72 hours of diagnosis to prevent complications.