The Murphy’s sign is a focused physical examination maneuver used by healthcare professionals to identify the source of abdominal pain. This simple, non-invasive technique provides diagnostic information, particularly in distinguishing gallbladder inflammation from other causes of discomfort in the upper right side of the abdomen. The sign serves as a rapid initial tool to guide further testing and management for patients presenting with acute abdominal symptoms.
The Technique and Physiological Mechanism
The procedure begins with the patient lying flat on their back. The clinician gently places fingers beneath the patient’s right costal margin, near the gallbladder’s location. The patient is instructed to take a slow, deep breath while the examiner maintains steady pressure.
A positive result is marked by a sudden, sharp pain that causes the patient to abruptly stop inhalation, known as an inspiratory arrest. When a person inhales deeply, the diaphragm contracts and moves downward, pushing the liver and gallbladder lower into the abdominal cavity.
If the gallbladder is acutely inflamed, this downward movement causes the organ to descend onto the examiner’s fingers. The resulting mechanical pressure triggers an intense pain response, forcing the patient to halt the breath. This mechanism ensures the pain is specifically related to the physical displacement of the inflamed gallbladder.
The Primary Diagnosis: Acute Cholecystitis
A positive Murphy’s sign is highly suggestive of acute cholecystitis, which is inflammation of the gallbladder. This condition typically arises when a gallstone lodges in the cystic duct, blocking bile exit. The resulting backup leads to increased pressure, distention, and inflammation of the gallbladder wall.
Most acute cholecystitis cases (approximately 90%) are calculous, meaning they are caused by gallstones. The remaining cases are acalculous cholecystitis, occurring without gallstones but often seen in individuals with severe illnesses or trauma. The pain is persistent, localized to the upper right abdomen, and often lasts longer than six hours.
The positive Murphy’s sign helps differentiate the persistent pain of cholecystitis from the episodic pain of biliary colic (gallbladder pain without inflammation). In the setting of right upper quadrant pain, the positive sign directs the diagnostic focus toward the gallbladder, speeding up the path to necessary treatment.
When the Sign is Negative or Misleading
While a positive Murphy’s sign strongly indicates acute cholecystitis, a negative result does not rule out the diagnosis. Other conditions causing upper right quadrant pain that do not elicit the sign include acute hepatitis, perforated peptic ulcers, or ascending cholangitis.
The sign can be falsely negative in certain circumstances, complicating assessment. Elderly patients may have a blunted pain response, or patients in severe pain may not inhale deeply enough for the gallbladder to descend. Additionally, patients with chronic cholecystitis may present with a negative sign.
A negative sign may also occur if the pain originates elsewhere, such as from kidney stones or pneumonia affecting the lower right lung lobe. Therefore, the physical exam finding must be combined with imaging studies and laboratory tests for an accurate diagnosis.