Murphy’s sign is a specific finding used during a physical examination to help differentiate the cause of pain felt in the upper-right area of the abdomen. This maneuver tests for localized tenderness, suggesting underlying inflammation of a visceral organ within that region. By applying gentle pressure and observing the patient’s reaction, clinicians can quickly localize the source of discomfort. The sign provides a quick, non-invasive method for assessing the hypersensitivity of organs situated beneath the rib cage, guiding the diagnostic process.
The Procedure for Eliciting the Sign
The test for Murphy’s sign begins with the patient lying flat on their back. The examiner first asks the patient to exhale fully, which helps relax the abdominal muscles and ensures deep palpation.
The clinician then places their fingers beneath the right costal margin (the edge of the rib cage) along the mid-clavicular line, marking the approximate anatomical location of the gallbladder. The examiner applies gentle but firm pressure inward and upward toward the liver.
Next, the patient is instructed to take a slow, deep breath. As the patient inhales, the diaphragm moves down, bringing the liver and the gallbladder closer to the examiner’s pressed fingers.
A result is considered positive if the patient suddenly stops inspiration due to an abrupt, sharp increase in pain. This sudden halt, often described as a “catch” in the breath, is an involuntary response to the inflamed organ making contact with the examiner’s hand. If the patient can take a full, deep breath without this sudden cessation of breathing, the sign is considered negative.
Acute Cholecystitis: The Primary Indication
A positive Murphy’s sign is recognized as the hallmark clinical finding for Acute Cholecystitis. This is a painful inflammation of the gallbladder, most often caused by a gallstone blocking the cystic duct. The obstruction traps bile, leading to distention and irritation of the organ’s wall.
The pathophysiology behind the positive sign is due to the inflamed, highly sensitive gallbladder descending with the liver during the deep breath. As the organ moves downward, it strikes the examiner’s fingers held firmly beneath the right costal margin. This mechanical contact on the irritated tissue triggers a sharp pain response.
This characteristic pain is a localized reaction caused by the stimulation of nociceptors in the gallbladder wall. Inflammation causes the release of chemical mediators that sensitize the pain receptors. The combination of inflammation and direct pressure leads to the involuntary inspiratory arrest.
Patients presenting with a positive Murphy’s sign usually experience continuous, severe pain in the right upper quadrant, which may radiate to the right shoulder blade or back. Common accompanying symptoms include fever, nausea, and vomiting. Although highly suggestive, the sign is typically combined with laboratory tests and imaging, such as an abdominal ultrasound, for a definitive diagnosis. The sign’s sensitivity can be lower in certain populations, such as elderly patients, or if the patient has already received pain medication.
Distinguishing Between Similar Clinical Findings
Pain in the right upper quadrant of the abdomen can stem from multiple sources, making the Murphy’s sign a valuable tool for differentiation. Several other conditions cause pain in the same general area but typically yield a negative Murphy’s sign.
These include choledocholithiasis, which is the presence of stones in the common bile duct, and ascending cholangitis, a severe infection of the bile ducts. Conditions such as hepatitis (inflammation of the liver) and certain types of peptic ulcer disease can also present with right upper quadrant discomfort.
In these cases, the gallbladder itself is not the primary source of inflammation, so the deep inspiration maneuver does not elicit the characteristic sharp, stopping pain. The absence of a positive sign helps redirect the clinician’s focus to other potential diagnoses.
It is also important to avoid confusing the abdominal Murphy’s sign with CVA tenderness, sometimes referred to as the “Murphy’s punch sign.” CVA tenderness is elicited by thumping the costovertebral angle, the area on the back over the kidney. A positive CVA tenderness suggests an issue with the kidney, such as pyelonephritis, and is completely unrelated to gallbladder pathology.