Murphy’s Sign: What It Means in Gallbladder Disease (Acute Cholecystitis)
What is Murphy’s sign?
Murphy’s sign is a clinical physical examination finding used to help diagnose acute cholecystitis (inflammation of the gallbladder). It was named after the American surgeon John Benjamin Murphy (1857‑1916). A positive Murphy’s sign indicates that the gallbladder is inflamed and tender, typically due to a gallstone impacted in the cystic duct. It is a classic sign taught in medical schools and used in emergency departments worldwide.
How to perform the Murphy’s sign test
The test is performed as follows:
- Place your hand (or fingers) over the patient’s right upper quadrant (RUQ), just below the costal margin (rib cage).
- Ask the patient to take a deep breath in.
- As the patient inhales, the diaphragm descends, pushing the liver and gallbladder downward against your hand.
- Positive Murphy’s sign: The patient abruptly stops breathing in (or has a “catch” in inspiration) due to sharp pain, and may even push your hand away.
- Negative Murphy’s sign: The patient can complete a deep breath without significant pain.
Positive vs negative – what the result means
- Positive Murphy’s sign: Highly suggestive of acute cholecystitis. The inflamed gallbladder contacts the parietal peritoneum during inspiration, causing sudden pain and inspiratory arrest.
- Negative Murphy’s sign: Does not exclude acute cholecystitis. In early cholecystitis, the gallbladder may not yet be severely inflamed. Also, patients with diabetes or older adults may have atypical presentations and a negative Murphy’s sign despite significant disease.
Sonographic Murphy’s sign – on ultrasound
Radiologists use a similar concept during a gallbladder ultrasound. The sonographic Murphy’s sign is considered positive when the patient experiences tenderness when the ultrasound probe is pressed directly over the gallbladder, and that tenderness is maximal over the gallbladder compared to other areas. It is a very specific finding for acute cholecystitis (sensitivity ~90%, specificity ~95%).
Sensitivity, specificity, and limitations
Based on meta‑analyses:
- Sensitivity: 60‑80% (many patients with acute cholecystitis may not have a positive Murphy’s sign).
- Specificity: 80‑95% (if positive, very likely to be acute cholecystitis, but false‑positives can occur).
- Limitations: Cannot be performed in sedated or uncooperative patients. May be falsely negative in elderly, diabetics (due to neuropathy), or those on analgesics. May be falsely positive in patients with right lower lobe pneumonia, hepatitis, or right renal pathology.
Other causes of a false‑positive Murphy’s sign
A positive Murphy’s sign is not exclusive to acute cholecystitis. Conditions that can mimic it include:
- Right lower lobe pneumonia (pleuritic pain during inspiration).
- Hepatitis (enlarged tender liver).
- Right‑sided pyelonephritis or renal colic.
- Peptic ulcer disease (if the ulcer is penetrating).
- Subphrenic abscess.
Conversely, acute cholecystitis may be present without a positive Murphy’s sign, especially in patients with gangrenous cholecystitis (the gallbladder may be necrotic and non‑tender).
Interactive FAQ – Murphy’s sign
Yes – acute acalculous cholecystitis (gallbladder inflammation without stones) can also cause a positive Murphy’s sign. This occurs in critically ill patients, after trauma, or with certain infections.
Yes – a positive test causes sharp pain during deep inspiration, prompting the patient to stop breathing. The test should be performed gently; do not force a deep breath if the patient is in severe pain.
No – it requires medical training to interpret correctly. Incorrect pressure could cause discomfort or misinterpretation. If you have right upper quadrant pain, see a doctor.
Boas’ sign is tenderness to palpation in the right lower back (over the 10th‑12th ribs) in acute cholecystitis. Murphy’s sign is anterior abdominal tenderness during inspiration. Both are suggestive of gallbladder disease but are not diagnostic alone.
Ultrasound is much more accurate and is the gold standard. Murphy’s sign is a bedside screening tool. Ultrasound provides definitive evidence of stones, wall thickening, and pericholecystic fluid.
Yes – up to 30‑40% of patients with acute cholecystitis may have a negative Murphy’s sign, especially elderly, diabetics, or those with gangrenous cholecystitis. Do not rule out the condition based on a negative exam.
It is tenderness elicited by pressing the ultrasound probe directly over the gallbladder during imaging. It is more specific than clinical Murphy’s sign for acute cholecystitis.
Yes – it is a classic physical exam finding taught to all medical students and residents. It remains a useful bedside test, though it should be used in conjunction with imaging.
Rarely. Biliary colic is usually intermittent and the gallbladder is not inflamed, so deep inspiration typically does not reproduce sharp pain. A positive Murphy’s sign suggests inflammation, not just stones.
Disclaimer: This information is for educational purposes. If you have right upper quadrant pain, consult a doctor at Vivekananda Hospital for proper evaluation – do not rely solely on physical exam findings.