A positive Murphy’s sign is a specific clinical finding suggesting that your gallbladder is inflamed, a condition called acute cholecystitis. During the test, a clinician presses firmly beneath your right rib cage and asks you to take a deep breath; if you involuntarily stop breathing in because of a sharp spike in pain, the sign is considered positive. Though it has been used in medicine for well over a century, the test is neither perfectly sensitive nor perfectly specific, and understanding what it actually tells your doctor requires knowing its strengths, its blind spots, and the conditions that can fool it.
How the Test Is Performed
The maneuver is straightforward. You lie on your back, and the examiner places their fingers or hand just below the edge of your right ribcage, roughly where the gallbladder sits beneath the liver. They apply steady, moderate pressure and ask you to inhale deeply. As your diaphragm pushes the liver and gallbladder downward, the inflamed gallbladder contacts the examiner’s fingers. If the gallbladder wall is swollen and irritated, this contact produces a sudden, sharp pain that causes you to catch your breath mid-inhale. That involuntary pause, sometimes called an “inspiratory arrest,” is what makes the sign positive.
A negative Murphy’s sign means you can inhale fully without that characteristic catch. Pain in the area without the inspiratory arrest does not count as a true positive. Similarly, the same maneuver performed on the left side of the abdomen should not produce the same response; if it does, the pain is likely coming from something other than the gallbladder, and many clinicians will consider the test unreliable.
The Sonographic Murphy Sign
There is a second version of the test that happens in the ultrasound suite rather than at the bedside. During a right-upper-quadrant ultrasound, the sonographer locates the gallbladder on screen and then presses the ultrasound probe directly over it. If that focused pressure produces maximal tenderness right over the sonographically confirmed gallbladder location, the finding is called a positive sonographic Murphy sign.1PubMed. Prospective evaluation of the sonographic Murphy sign in suspected acute cholecystitis The advantage here is precision: the examiner knows exactly where the gallbladder is, rather than estimating based on anatomy that varies from person to person.
The sonographic version has been reported as a helpful adjunctive finding in patients who turn out to have confirmed acute cholecystitis.2PubMed. Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis In practice, the sonographic Murphy sign is often evaluated alongside other ultrasound findings like gallstones, gallbladder wall thickening, and fluid around the gallbladder. No single finding confirms the diagnosis on its own, but a positive sonographic Murphy sign combined with stones and a thickened wall paints a convincing picture.
What a Positive Murphy’s Sign Actually Tells Your Doctor
A positive Murphy’s sign is one piece of a diagnostic puzzle, not a standalone diagnosis. The widely referenced Tokyo Guidelines, which are used internationally to standardize the diagnosis of acute cholecystitis, lay out a combination of findings that together point to the condition. A patient who has a local sign of inflammation such as Murphy’s sign or right-upper-quadrant tenderness, along with a systemic sign of inflammation such as fever, an elevated white blood cell count, or elevated C-reactive protein, meets the clinical criteria for suspected acute cholecystitis.3PubMed Central. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines
However, the updated Tokyo Guidelines also make clear that a definite diagnosis can only be made with imaging confirmation through ultrasound, CT, or a nuclear medicine scan called a HIDA scan.4PubMed. TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos) So a positive Murphy’s sign raises the clinical suspicion high enough to order those imaging studies. It opens the door to the workup rather than closing the diagnostic loop by itself.
In an emergency department, a patient with right-upper-quadrant pain, a low-grade fever, and a positive Murphy’s sign will almost certainly get a right-upper-quadrant ultrasound within hours. The sign helps the clinician prioritize what to look for and how quickly to act.
When the Sign Is Unreliable in Older Adults
One of the most clinically important limitations of Murphy’s sign is that it becomes less reliable as patients age. A study specifically examining the test in elderly patients found that the positive predictive value dropped to about 0.58, meaning that roughly four in ten elderly patients with a positive Murphy’s sign did not actually have acute cholecystitis. The sensitivity was even more concerning at 0.48, which means the test missed more than half of the elderly patients who truly had the condition. Specificity was better at 0.79, but the overall message was clear: in older patients, a positive Murphy’s sign is still worth noting, but a negative sign should be treated with real caution.5PubMed. Murphy’s sign, acute cholecystitis and elderly people
Several factors contribute to this. Older adults often have a blunted pain response. Some have chronic abdominal conditions or prior surgeries that alter the anatomy or the sensation in the area. Others may be on medications that dull pain perception. The practical takeaway for older patients and their families is that the absence of the sign does not rule out gallbladder inflammation. Doctors are generally advised to pursue imaging promptly in elderly patients with right-upper-quadrant symptoms even when the physical exam is equivocal.
How Pain Medication Can Mask the Sign
If you arrive at an emergency department in significant pain and receive opioid analgesics before your ultrasound, it can meaningfully change the results. A study examining whether analgesia affects the sonographic Murphy sign found that patients who received opioid analgesics before their ultrasound had a false-negative rate of about 8%, compared to 3% in patients who had not received pain medication. Even low doses, equivalent to less than 4 milligrams of morphine, were enough to produce a statistically significant increase in missed diagnoses. Patients who received opioids within 30 minutes of the ultrasound exam were particularly affected, with a false-negative rate of about 8.5%.6PubMed Central. The sonographic Murphy sign: does analgesia matter?
This creates a genuine clinical tension. Clinicians do not want to withhold pain relief from someone in distress, but giving opioids before the ultrasound can suppress the very tenderness that helps confirm the diagnosis. In the study, 24 cases of acute cholecystitis were initially missed on imaging but were fortunately caught because clinicians maintained a high level of suspicion despite the reassuring scan. The finding underscores why clinical judgment and repeat assessment sometimes matter as much as any single test result.
Conditions That Can Produce a False Positive
A positive Murphy’s sign does not always mean the gallbladder is the problem. Several conditions cause right-upper-quadrant pain that worsens with breathing, which can mimic gallbladder inflammation closely enough to produce the same clinical finding. One documented mimic is Fitz-Hugh-Curtis syndrome, a complication of pelvic inflammatory disease in which infection spreads to the liver capsule and creates adhesions between the liver and the abdominal wall. These adhesions cause right-upper-quadrant pain that gets worse with breathing because the liver moves against the inflamed tissue. The pain can be severe enough to trigger a positive Murphy’s sign, leading clinicians down the wrong diagnostic path toward gallbladder disease.7PubMed Central. Positive Murphy’s Sign of Fitz-Hugh-Curtis Syndrome
Other conditions in the differential include hepatitis, liver abscess, right-sided pneumonia that irritates the diaphragm, and peptic ulcer disease. Even a distended or inflamed hepatic flexure of the colon can occasionally provoke tenderness in the same area. This is why imaging is considered essential for confirmation. The Murphy’s sign tells the clinician where the pain is and how it behaves, but it cannot reveal the underlying structure responsible.
Murphy’s Sign in Children
Acute cholecystitis is far less common in children than in adults, but it does occur, particularly in children with hemolytic anemias like sickle cell disease or in adolescents with obesity. When it does, the physical exam is even less reliable than in adults. A study examining ultrasound sensitivity in pediatric cholecystitis found that Murphy’s sign had a sensitivity of only 6%, making it nearly useless as a screening finding in children. Its positive predictive value was about 67%, meaning that when it was present it was somewhat useful, but it was present so rarely that clinicians could not rely on it.8Journal of Surgical Research. Sensitivity and predictive value of ultrasound in pediatric cholecystitis
The reasons are partly practical. Young children cannot always cooperate with the exam. They may cry, tense their abdominal muscles, or be unable to follow the instruction to breathe in on command. Even in cooperative older children, the anatomy can vary enough that the examiner’s hand or the ultrasound probe is not positioned perfectly over the gallbladder. For pediatric patients, other ultrasound findings like gallstones and gallbladder sludge carry far more diagnostic weight than the Murphy sign does.
Critically Ill Patients and Acalculous Cholecystitis
In intensive care settings, the rules change again. Critically ill patients can develop gallbladder inflammation without any gallstones at all, a condition called acalculous cholecystitis. This tends to happen in patients who are on mechanical ventilation, receiving total parenteral nutrition, or recovering from major surgery or trauma. A study of ICU patients who underwent gallbladder ultrasounds found that a large majority, roughly 84%, had at least one sonographic gallbladder abnormality while in the ICU. Yet no statistically significant correlation was found between these sonographic abnormalities and the patients’ clinical or laboratory parameters.9American Journal of Roentgenology (AJR). Prevalence and significance of gallbladder abnormalities seen on sonography in intensive care unit patients
This means that in the ICU, gallbladder ultrasound findings are common, often incidental, and difficult to interpret. A sedated or unconscious patient cannot report tenderness, so Murphy’s sign is essentially unobtainable. Clinicians have to rely on indirect clues like unexplained sepsis, rising inflammatory markers, or worsening liver function tests to suspect acalculous cholecystitis. Diagnosis in this population often requires a HIDA scan or even diagnostic laparoscopy rather than the bedside exam that works well in awake, cooperative outpatients.
What Happens After Acute Cholecystitis Is Confirmed
Once imaging and clinical findings converge on a diagnosis of acute cholecystitis, the standard treatment is surgical removal of the gallbladder, known as laparoscopic cholecystectomy. A longstanding question in surgery has been whether to operate early, within about 72 hours of admission, or to cool things down with antibiotics and fluids and schedule surgery weeks later. A randomized trial comparing early versus delayed laparoscopic cholecystectomy in 224 patients with acute cholecystitis found that early surgery was safe and feasible, with reduced hospital stays and without increasing complication rates or mortality compared to the delayed approach.10Acta Medica International. Comparative Study Between Early Versus Delayed Laparoscopic Cholecystectomy in Acute Cholecystitis
The trend in surgical practice has been shifting toward early cholecystectomy for several reasons. Patients who go home on conservative management and return weeks later for surgery sometimes experience a recurrent attack in the interim, occasionally a severe one. Early surgery also means a single hospital admission rather than two, which has both clinical and economic advantages. For patients whose Murphy’s sign and imaging have confirmed the diagnosis, the conversation with the surgical team often turns quickly to when, not whether, the gallbladder should come out.
The History Behind the Name
The sign is named after John Benjamin Murphy, a prominent American surgeon who practiced in Chicago in the late 1800s and early 1900s. Murphy was known for bold surgical innovation and had a flair for clinical teaching. He described the maneuver as a way to localize gallbladder tenderness at a time when abdominal imaging did not exist and surgeons had to rely entirely on their hands and their patients’ responses. The fact that the test still bears his name and remains part of the standard physical examination more than a century later is a testament to its practical value, even as the diagnostic landscape around it has grown enormously more sophisticated.
What Murphy could not have anticipated is the sonographic adaptation of his sign, which marries the physical exam with real-time imaging. The two versions of the test are sometimes treated interchangeably in casual discussion, but they have different performance characteristics and are done in different settings. The bedside clinical Murphy’s sign is a screening tool that any clinician can perform immediately. The sonographic Murphy sign is a confirmatory finding that requires an ultrasound machine and a trained operator. Both have value, but they answer slightly different questions at different points in the diagnostic process.
Why It Still Matters in Modern Medicine
Given advanced imaging, blood tests, and surgical capabilities, it is fair to ask whether a 19th-century physical exam maneuver still has a place. The answer from the evidence is a qualified yes. Murphy’s sign remains embedded in internationally adopted diagnostic guidelines for acute cholecystitis.3PubMed Central. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines It is quick, free, requires no equipment, and can be performed in any setting from a rural clinic to a busy emergency department. For a young, otherwise healthy adult with classic right-upper-quadrant pain, the test performs well enough to rapidly focus the clinical picture and guide the decision to image.
Its weaknesses are real and well documented. It underperforms in older adults, children, the critically ill, and patients who have recently received pain medication. It can be fooled by hepatic, pulmonary, and gynecological conditions that produce overlapping symptoms. No experienced clinician treats a positive Murphy’s sign as a final diagnosis, and no experienced clinician dismisses a negative result in a patient whose story strongly suggests gallbladder trouble. The sign’s enduring role is as a first-pass sorting tool: fast, informative when positive, and a prompt for further investigation when the clinical picture does not quite add up.