Murphy’s sign is a technique used during a physical examination to help differentiate sources of pain in the upper right side of the abdomen. This diagnostic maneuver assesses tenderness related to the gallbladder, often indicating inflammation. The test relies on a patient’s involuntary reaction to pressure applied beneath the rib cage while they take a deep breath. It serves as a rapid screening tool to guide further investigation into potential gallbladder disease.
The Anatomy of Gallbladder Pain
The gallbladder is a small, pear-shaped organ tucked beneath the liver in the right upper quadrant of the abdomen. When this organ becomes inflamed, a condition known as cholecystitis, its walls swell and become sensitive to touch. The pain reaction during Murphy’s sign is related to the movement of the diaphragm. During a deep inhalation, the diaphragm contracts and moves downward, pushing the liver and the underlying gallbladder inferiorly. If the gallbladder is inflamed, this downward motion forces the tender organ directly against the examining fingers pressed into the abdomen, causing a sharp, sudden increase in pain.
How the Clinical Test is Performed
To perform the Murphy’s sign, the patient lies flat on their back in a relaxed position. The clinician begins by locating the precise area where the gallbladder is expected to descend during inspiration. This location is found by palpating the right upper quadrant, specifically where the rectus abdominis muscle meets the lower edge of the rib cage (costal margin). The examiner then gently applies steady, deep pressure with their fingers or thumb into this area, instructing the patient to take a slow, deep breath in while pressure is maintained. The clinician observes the patient’s face and breathing pattern to see if the internal movement of the gallbladder causes a painful interruption.
What a Positive Finding Indicates
A positive Murphy’s sign is defined by the sudden, involuntary cessation of the patient’s inspiration due to a sharp increase in pain. The pain is severe enough to cause the patient to “catch” their breath or wince, stopping the deep inhalation before it is complete. The finding is highly suggestive of acute cholecystitis, which is typically caused by a gallstone blocking the cystic duct, leading to inflammation. A negative sign means the patient is able to complete the deep breath without any sudden pain or interruption, even with the pressure applied. While a positive sign points strongly to an inflamed gallbladder, it is not a definitive diagnosis and requires confirmation with other tests, such as blood work and an abdominal ultrasound.
When the Sign May Be Unreliable
Murphy’s sign is not perfectly reliable and can produce misleading results. One common limitation involves elderly patients, who may have a diminished perception of pain due to age-related changes in nerve sensitivity, meaning a negative sign does not effectively rule out acute cholecystitis. False negative results may also occur if the patient is experiencing chronic, rather than acute, gallbladder inflammation, which may not cause enough tenderness to elicit the characteristic pain response. Anatomical variation, where the gallbladder is positioned unusually deep within the abdomen, can prevent it from being adequately compressed by the examining fingers. Furthermore, a positive sign is not exclusive to the gallbladder; conditions such as hepatitis or pyelonephritis can sometimes cause tenderness in the same general area, requiring a comprehensive diagnostic workup to differentiate the true cause of the patient’s discomfort.