Murphy’s sign is a specific physical examination maneuver used to help determine the source of pain in the upper right side of the abdomen. This simple test involves pressing on a particular area while the patient breathes in deeply. The maneuver relies on the normal movement of organs during respiration. Observing the patient’s reaction to this pressure provides valuable information about the underlying condition causing their discomfort.
Purpose and Patient Preparation
The primary reason for performing Murphy’s sign is to screen for acute cholecystitis, which is inflammation of the gallbladder. This inflammation often occurs when a gallstone blocks the cystic duct, causing the gallbladder to become distended and highly sensitive to touch. When the inflamed gallbladder is disturbed, it generates a sharp pain that interrupts the patient’s breathing pattern.
To correctly perform the test, the patient must be positioned lying flat on their back (supine position). This positioning allows the abdominal muscles to relax and makes the area under the ribcage more accessible for the examiner. The patient should relax and expose their abdomen for a proper assessment.
The test relies on the downward movement of the diaphragm during inspiration. When the patient takes a deep breath, the diaphragm contracts and pushes the liver and attached gallbladder down. The examiner places their hand in the right upper quadrant, specifically under the right costal margin (the edge of the ribcage). This positioning allows the examiner to anticipate the gallbladder’s movement and make contact with it as it descends.
Step-by-Step Guide for Eliciting the Sign
The procedure begins with the examiner standing on the patient’s right side and locating the precise area for palpation. The examiner’s fingers, or specifically the thumb, are placed just under the lower edge of the right ribcage, aligning with the mid-clavicular line. The patient should first be asked to exhale fully to help the examiner hook their fingers deeper beneath the costal margin.
Once the hand is correctly positioned, the examiner applies gentle but firm pressure inward and upward into the abdomen. This pressure should be maintained throughout the next step. The action is designed to position the examiner’s fingers directly in the path of the descending gallbladder.
The patient is then instructed to take a full, deep breath. As the patient inhales, the diaphragm moves downward, bringing the liver and gallbladder closer to the examiner’s hand. The pressure from the examiner’s fingers will make contact with the gallbladder.
Throughout the deep inspiration, the examiner must observe the patient’s breathing pattern and facial expression. The key is to watch for any sudden, involuntary cessation of the breath or a wince of pain. The patient’s reaction is a direct result of the tender, inflamed gallbladder being pressed against the examiner’s hand.
To ensure the pain is specific to the gallbladder, the maneuver can be repeated on the left side of the abdomen. This comparison helps rule out generalized abdominal tenderness or lack of patient cooperation, as the left side should not cause the same painful reaction.
Understanding Positive and Negative Findings
A positive Murphy’s sign is defined by a sharp, involuntary halt in the patient’s inspiration. The patient will suddenly stop inhaling and often gasp or wince due to a pronounced increase in pain as the inflamed gallbladder touches the examiner’s fingers. This abrupt cessation of breath, typically occurring toward the end of the full inspiration, is highly suggestive of acute cholecystitis.
A positive result indicates that the gallbladder is likely inflamed, as the pain experienced is a direct response to the movement and compression of the tender organ. Clinicians use this finding as strong evidence to guide further diagnostic tests, such as an abdominal ultrasound, to confirm the diagnosis. Although the sign has a high sensitivity for detecting the condition, it is not considered definitive on its own.
Conversely, a negative Murphy’s sign occurs when the patient completes a full, deep inspiration without experiencing significant pain or a sudden stop in their breathing. This result suggests that acute cholecystitis is less likely to be the cause of the patient’s right upper quadrant pain. However, a negative finding does not completely exclude gallbladder issues, especially in older patients where the sign may be less reliable.
The absence of a positive sign may prompt the clinician to consider other potential causes for upper right abdominal pain, such as kidney infection or ascending cholangitis. Therefore, the result of the Murphy’s sign is always interpreted within the context of the patient’s overall symptoms and history.