A positive Murphy’s sign is a finding observed during a physical examination used to diagnose specific causes of abdominal pain. This clinical indicator is elicited by a healthcare provider applying pressure to the upper right quadrant of the abdomen. The patient’s reaction to this maneuver suggests inflammation in the underlying organs. The test is primarily used as a quick, bedside method to narrow diagnostic possibilities, guiding the practitioner toward conditions affecting the gallbladder.
The Physical Examination Technique
The procedure requires the patient to be lying flat on their back. The examiner gently places their hand over the patient’s right upper quadrant, targeting the subcostal margin near the mid-clavicular line. This area is located just beneath the rib cage where the gallbladder resides.
The patient is then instructed to take a slow, deep breath while the examiner maintains firm pressure on the area. During deep inhalation, the diaphragm contracts and pushes the abdominal organs, including the liver and gallbladder, downward. This maneuver is designed to bring the gallbladder into contact with the examiner’s fingertips.
A positive Murphy’s sign is defined by an involuntary, sudden cessation of the patient’s breathing, known as inspiratory arrest, due to a sharp increase in pain. This inspiratory arrest is the defining feature, distinguishing the sign from simple tenderness or general discomfort. The pain is intense enough to override the patient’s effort to continue taking a deep breath.
Acute Cholecystitis: The Primary Diagnosis
When a patient demonstrates a positive Murphy’s sign, it strongly suggests Acute Cholecystitis, which is inflammation of the gallbladder. This condition is most commonly caused by a gallstone blocking the cystic duct, the channel leading out of the gallbladder. The resulting obstruction leads to fluid buildup and inflammation within the organ, making its wall sensitive.
The mechanism behind the positive test is directly related to this inflammatory process. As the patient inhales deeply, the downward movement of the diaphragm pushes the inflamed and tender gallbladder directly onto the examiner’s hand. The contact with the sensitive, swollen organ causes sudden, sharp visceral pain. This pain reflexively causes the patient to stop inhaling, triggering the diagnostic inspiratory arrest.
Acute Cholecystitis usually presents with other symptoms accompanying the positive sign. Patients often report persistent pain in the upper right abdomen, which may radiate to the right shoulder or back, along with fever, nausea, and vomiting. The presence of a positive Murphy’s sign alongside these clinical symptoms forms a strong initial basis for a provisional diagnosis. This finding helps differentiate gallbladder inflammation from other abdominal pain sources that cause tenderness but lack the characteristic inspiratory arrest.
Factors Affecting the Reliability of the Test
While a positive Murphy’s sign suggests Acute Cholecystitis, the test is not definitive and has known limitations. For instance, the test can produce a false negative result, meaning the sign is absent even when the disease is present.
This situation occurs particularly in elderly patients, who may have a diminished perception of pain, or in those with severe generalized abdominal pain that prevents cooperation with the deep breath instruction. Additionally, if the patient has received strong pain medication before the examination, the medication may mask the sharp pain response, also leading to a false negative result.
Furthermore, other conditions, such as pyelonephritis (a kidney infection) or hepatitis (liver inflammation), can sometimes cause pain in the right upper quadrant. Because of these factors, Murphy’s sign is considered a clinical indicator that must be used as part of a broader clinical assessment. A conclusive diagnosis requires confirmation through diagnostic imaging, most often an abdominal ultrasound, which can directly visualize signs of inflammation like gallbladder wall thickening or the presence of gallstones.