What Does a Negative Murphy’s Sign Indicate?

A negative Murphy’s sign means the patient does not catch their breath or stop inhaling when the examiner presses beneath the right rib cage. In clinical practice, this is generally taken as evidence against acute cholecystitis, the most common reason gallbladder inflammation sends people to the emergency department. But the sign is far from foolproof, and a negative result does not rule out gallbladder disease or other serious conditions that produce similar pain. How much weight a negative Murphy’s sign carries depends heavily on context: the patient’s age, body habitus, whether they are critically ill, and what other findings are present.

What the Sign Actually Tests

Murphy’s sign exploits a straightforward anatomical relationship. During a deep breath, the diaphragm pushes the liver and gallbladder downward. If the gallbladder is acutely inflamed, it slides into contact with the examiner’s fingers pressed just below the right costal margin, and the patient involuntarily stops breathing because of the sudden sharp pain. A positive result suggests the gallbladder wall is swollen and tender enough to produce that abrupt inspiratory arrest. A negative result means the maneuver did not provoke that response, which in many patients correctly points away from acute cholecystitis and toward other causes of right upper quadrant pain.

The test is quick, free, and requires no equipment, which is why it remains a staple of bedside evaluation more than a century after it was first described. It is typically one of the first things an emergency physician or surgeon checks when someone presents with pain under the right rib cage, fever, and nausea. But like all physical examination findings, it is a screening clue rather than a definitive answer.

How Accurate Is a Negative Murphy’s Sign

The numbers vary depending on who is being examined and who is doing the examining. In one study focused specifically on elderly patients, the diagnostic accuracy of the test dropped to just 34% when the sign was negative, compared with 80% when it was positive. The sensitivity in older adults was only about 48%, meaning the test missed roughly half of all cases of acute cholecystitis in that age group.¹ Those numbers highlight a critical point: a negative Murphy’s sign in an older patient provides little reassurance. Other diagnostic steps should follow promptly.

In younger, otherwise healthy populations, the test tends to perform better, largely because the classic presentation of acute cholecystitis is more reliable in that group. But even in the best circumstances, Murphy’s sign is one data point among many. No experienced clinician would send someone home based on a single negative physical exam finding when the rest of the picture suggests gallbladder trouble.

Why the Sign Fails in Certain Patients

Several situations make Murphy’s sign unreliable or outright misleading. Understanding these helps explain why your doctor might order further testing even after the exam seems reassuring.

Older adults: Elderly patients frequently have blunted pain responses and atypical presentations of acute illness. Gallbladder inflammation that would cause obvious guarding and inspiratory arrest in a 35-year-old may produce only vague discomfort in a 75-year-old. As the data above show, sensitivity drops considerably in this group.¹
Critically ill or sedated patients: People on ventilators, under heavy sedation, or with altered consciousness cannot cooperate with the breathing maneuver the test requires. In intensive care settings, Murphy’s sign is essentially unusable.
Obesity: A thick abdominal wall makes it difficult for the examiner to localize pressure precisely over the gallbladder fossa. The inflamed organ may not come into adequate contact with the examiner’s fingers, producing a falsely negative result.
Gangrenous cholecystitis: When the gallbladder wall has become necrotic, the nerve fibers that transmit pain may be destroyed. Paradoxically, this most dangerous form of cholecystitis can present with a negative Murphy’s sign because the tissue is too damaged to signal pain normally. This is one reason surgeons worry when laboratory values and imaging look bad but the exam seems benign.
Chronic cholecystitis: Patients with longstanding, low-grade gallbladder inflammation may not exhibit the acute tenderness that Murphy’s sign detects. Their gallbladder wall has thickened gradually, and their symptoms tend to be episodic rather than sudden.

The common thread is that Murphy’s sign depends on the patient being alert, cooperative, and capable of a normal pain response, and it depends on the gallbladder being acutely (not chronically or necrotically) inflamed. When any of those conditions are missing, the test loses its value.

The Sonographic Murphy Sign

There is a related but distinct test performed during an abdominal ultrasound. Instead of the examiner’s hand, the ultrasound transducer is pressed directly over the gallbladder while the sonographer watches the screen to confirm they are applying pressure in exactly the right spot. If the patient reports maximal tenderness when the transducer is directly over the gallbladder, the sonographic Murphy sign is positive.

This version has some advantages over the bedside exam. The sonographer can verify anatomically that they are pressing on the gallbladder rather than on a nearby structure like the hepatic flexure of the colon. In a prospective evaluation of the sonographic Murphy sign, the specificity was about 94% and the predictive value of a negative result was roughly 90%, meaning that when the sonographic Murphy sign was negative, about nine out of ten patients truly did not have acute cholecystitis.² The sensitivity was lower, around 63%, reflecting the same limitations that plague the bedside version: some patients with genuine cholecystitis simply do not exhibit the expected pain response.

Ultrasound also provides additional information beyond the Murphy sign itself. Wall thickening, pericholecystic fluid, gallstones, and gallbladder distension all contribute to the diagnosis. When those structural findings are absent and the sonographic Murphy sign is also negative, the combined picture is fairly strong evidence against acute cholecystitis. When the structural findings are present but the Murphy sign is negative, clinicians stay concerned.

Conditions That Mimic Gallbladder Disease

A negative Murphy’s sign does not mean the patient’s right upper quadrant pain is imaginary. It may simply point away from the gallbladder and toward something else entirely. The differential diagnosis for pain in that region of the abdomen is surprisingly broad.

Liver-Related Causes

The liver occupies most of the right upper quadrant, and a range of hepatic problems can produce localized pain and tenderness. Hepatitis, liver abscess, and even tumors can present with fever and right-sided pain that initially looks a lot like cholecystitis. A case report described a patient who presented with two weeks of fever and right upper quadrant pain whose workup ultimately revealed hepatocellular carcinoma manifesting initially as a pyogenic liver abscess.³ In such cases, Murphy’s sign would be negative because the gallbladder itself is not inflamed, but the pain is no less real or urgent.

Fitz-Hugh-Curtis Syndrome

This condition, caused by inflammation of the liver capsule in association with pelvic inflammatory disease (PID), is a classic diagnostic trap. It presents with sharp right upper quadrant pain that worsens with breathing and movement, closely mimicking cholecystitis. Because the gallbladder is uninvolved, Murphy’s sign is typically negative, and ultrasound shows no gallstones or gallbladder wall changes. Fitz-Hugh-Curtis syndrome occurs in up to one-fourth of patients with PID and is usually linked to Chlamydia trachomatis or Neisseria gonorrhoeae infection.⁴

The diagnosis is especially easy to miss in young women who do not report gynecological symptoms. In one case, a 22-year-old woman presented with right upper quadrant pain and fever, and imaging showed perihepatic fluid and fluid in the pelvis but no hepatic or biliary pathology.⁵ In another case, a young woman with similar symptoms and no gallstones was ultimately diagnosed after urine testing came back positive for Chlamydia trachomatis.⁶ The lesson is that in women of reproductive age with right upper quadrant pain and a negative Murphy’s sign, pelvic infection should be actively considered.

Other Mimics

Right lower lobe pneumonia can refer pain to the upper abdomen through irritation of the diaphragm. Peptic ulcer disease, particularly duodenal ulcers, can produce pain that the patient localizes to the right upper quadrant. Kidney stones or pyelonephritis on the right side occasionally present with anterior abdominal pain. Even cardiac events, particularly inferior wall heart attacks, can manifest as upper abdominal discomfort. In all of these situations, Murphy’s sign would be expected to be negative because the gallbladder is not the source of the problem.

Acalculous Cholecystitis and the Limits of the Standard Workup

One scenario that particularly challenges clinicians is acalculous cholecystitis, an inflammation of the gallbladder that occurs without gallstones. This form accounts for a meaningful minority of all cholecystitis cases and tends to arise in critically ill patients who are hospitalized for other reasons, such as major surgery, burns, prolonged ICU stays, or sepsis. Because these patients are often sedated or unable to communicate, the bedside Murphy’s sign is unreliable or impossible to perform. And because there are no stones to see on ultrasound, the most obvious imaging finding is absent.

When clinical suspicion for cholecystitis remains high despite a negative Murphy’s sign and even a normal-appearing ultrasound and CT scan, clinicians sometimes turn to a HIDA scan (hepatobiliary iminodiacetic acid scan). This nuclear medicine study tracks a radioactive tracer as it is taken up by the liver and excreted into the bile ducts and gallbladder. If the gallbladder does not fill with the tracer, the result is read as positive for cystic duct obstruction, supporting the diagnosis of acute cholecystitis. A case report documented a patient with high clinical suspicion for acute cholecystitis whose ultrasound and CT scan were both negative; a subsequent HIDA scan confirmed the diagnosis.⁷ This illustrates the principle that no single test, whether bedside or imaging-based, can completely exclude gallbladder disease when the clinical picture is suspicious.

What Clinicians Actually Do With a Negative Result

In practice, a negative Murphy’s sign shifts the probability of acute cholecystitis downward but does not eliminate it. What happens next depends on the rest of the clinical picture. If the patient has mild, vague pain, normal blood work, and no fever, a negative Murphy’s sign provides genuine reassurance and may be part of the reasoning for monitoring rather than ordering urgent imaging. If the patient has high fevers, elevated white blood cell counts, abnormal liver enzymes, and a history consistent with biliary disease, clinicians will move to ultrasound regardless of what the physical exam showed.

Emergency physicians tend to think of diagnostic tests in terms of pre-test and post-test probability. You start with a rough sense of how likely a given diagnosis is based on the patient’s story and risk factors. A positive or negative physical finding then adjusts that probability. A negative Murphy’s sign in a low-probability patient might be enough to confidently move on. A negative Murphy’s sign in a high-probability patient barely changes the picture. This is why two patients can have the same exam finding but receive very different workups.

Blood tests also factor in heavily. An elevated white blood cell count, particularly with a leftward shift in the differential, raises concern for infection. Elevated bilirubin or alkaline phosphatase can suggest biliary obstruction. C-reactive protein may be markedly elevated. When these laboratory findings are abnormal and the ultrasound shows gallstones or wall thickening, the diagnosis of acute cholecystitis is usually secure even without a positive Murphy’s sign.

Age-Specific Considerations

The unreliability of Murphy’s sign in older adults deserves extra emphasis because elderly patients also face the highest risk of complications from gallbladder disease. Gallbladder perforation, empyema (pus-filled gallbladder), and gangrenous cholecystitis are all more common in older patients, and delays in diagnosis directly increase the risk of these complications. The irony is that the patients who need the earliest and most aggressive workup are exactly the patients in whom the bedside exam is least helpful.

In elderly patients presenting with right upper quadrant pain, most guidelines effectively recommend proceeding straight to imaging without relying heavily on physical examination findings. The threshold for ordering an ultrasound is low, and if the ultrasound is equivocal, CT or HIDA scanning follows quickly. A negative Murphy’s sign in a 78-year-old with abdominal pain should not delay these steps.¹

When a Negative Sign Is Genuinely Useful

For all its limitations, Murphy’s sign is not useless. The test performs best in younger, non-obese adults who are awake, alert, and able to cooperate with the examination. In those patients, a clearly negative Murphy’s sign combined with a pain pattern that does not fit the classic biliary colic story can legitimately steer the workup in a different direction. A patient with right upper quadrant tenderness but no inspiratory arrest, normal-appearing gallbladder on ultrasound, and pain that worsens with coughing might prompt consideration of a musculoskeletal cause or a right lower lobe pulmonary process instead.

The sonographic version adds value here too. When an ultrasound shows a normal gallbladder with no stones, no wall thickening, no pericholecystic fluid, and a negative sonographic Murphy sign, the combination carries a negative predictive value around 90%.² That is strong enough to redirect clinical attention toward other diagnoses in most situations. The key word is “combination.” No single element of the exam or imaging study is meant to stand alone. It is the convergence of multiple normal findings that provides real diagnostic confidence.

In women of reproductive age, a negative Murphy’s sign paired with unremarkable biliary imaging should specifically prompt consideration of Fitz-Hugh-Curtis syndrome, especially if there is a history of vaginal discharge, pelvic pain, or prior sexually transmitted infection.⁴ Screening for Chlamydia and gonorrhea in this clinical context is simple, inexpensive, and can spare the patient unnecessary surgical referrals for a problem that is treated with antibiotics rather than cholecystectomy.

1
PubMed. Murphy’s sign, acute cholecystitis and elderly people
2
PubMed. Prospective evaluation of the sonographic Murphy sign in suspected acute cholecystitis
3
PubMed Central. The Abscess That Was Cancer: Pyogenic Liver Abscess as the Initial Manifestation of Hepatocellular Carcinoma in a Noncirrhotic Patient
4
PubMed. Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain
5
Anatolian Journal of Emergency Medicine. Fitz Hugh Curtis Syndrome in a Patient Presenting with Right Upper Quadrant Pain: A Case Report
6
PubMed Central. Fitz-Hugh-Curtis Syndrome: A Diagnosis to Consider in a Woman with Right Upper Quadrant Abdominal Pain without Gallstones
7
PubMed Central. Acute Acalculous Cholecystitis in the Setting of Negative Ultrasound and Computed Tomography Scan of the Abdomen