Murphy’s Sign

What is Murphy’s sign?

It is a finding for differentiating the cause, by physical examination of a patient having pain in the right upper quadrant of the abdomen ⁽¹⁾. This test is positive if the patient is having acute cholecystitis (inflammation of the gallbladder) ⁽¹⁾.

John Benjamin Murphy was the American Surgeon who described the sign first.

Position of Gallbladder in abdomen

Gallbladder is situated under the liver on the right side of abdomen, which is on the right upper quadrant. To see what other organs are situated on the right upper quadrant, click here  “Abdominal Pain”.

Picture 1: Image showing the position of gallbladder under the liver. The green coloured structure shown is gallbladder.

Picture 2: Image showing the four quadrants of the abdomen with the contents of right upper quadrant (RUQ).

On a person, it is actually difficult to palpate a gallbladder by palpating the abdomen. If the person is suffering with pain in the right upper quadrant due to acute cholecystitis, then the palpation of the site elicits a painful reaction from him. It is easy to understand where the manoeuvre is done if you can identify a few points on your abdomen.

1. Identify the lower margin of the rib cage on your abdomen (costal margin). It is more like an inverted ‘V’.
2. Now, draw an imaginary line downwards (towards abdomen) from the middle of your right collar bone (clavicle) – Right mid-clavicular line ⁽²⁾.
3. The junction between the lower margin of the right side of the rib cage (right side of the costal margin) and the line described above is the point under which gallbladder can be palpated.
4. This is also the tip of right 9th coastal cartilage ⁽³⁾.
5. It is the junction between the lower margin of the right side of the rib cage (right side of the costal margin) and outer border of rectus abdominis muscle ⁽³⁾.

Picture 3: Note the diaphragm, liver, costal margin and gallbladder, in the picture. Remember that abdomen is the area below diaphragm.

How is Murphy’s sign elicited?

The test can be done in different ways. The test is usually down with the patient in a lying position. The examiner stands on the right side of the patient and keeps his/her right palm on the patient’s abdomen. The palm is in fact placed just below the right costal margin near to the right mid-clavicular line. This is the position of gallbladder inside the abdomen^{(2, 5)}.

The patient is asked to exhale (breathe out) and then inhale (breathe in) deeply after the placement of the hand. When the patient inhales, the lungs get filled by air and the diaphragm is pulled downward towards the abdomen. We have seen above that diaphragm lies above the liver. See the Liver pain location.

When diaphragm is pulled downwards, the liver and gallbladder is pushed downwards too. If the gallbladder is inflamed as in case of acute cholecystitis, the patient will suddenly catch his/her breathe (due to sudden pain), when the finger of the examiner touches the gallbladder.

Picture 4: Image showing examination of abdomen of a patient to check for Murphy’s sign.

How to test for Murphy’s sign – VIDEO

What is a Positive Murphy’s sign?

When the manoeuvre is done in a patient with abdominal pain in the right upper quadrant, and the test elicits tenderness or sudden pain at the site, then the test is called positive or Murphy’s sign positive ⁽⁴⁾.

The test becomes positive in acute cholecystitis (inflammation of the gallbladder).

Picture 5: Change in gallbladder wall in acute cholecystitis.

What is Negative Murphy’s sign?

If there is no pain or sudden tenderness on examination of the patient, at the site, then it is a negative Murphy’s sign. It is important to remember that if the patient has taken strong pain killers, or if the examiner is doing the test at a wrong location on the abdomen, the test may become negative, even when the patient is having acute cholecystitis ⁽⁵⁾.

It is called as a false negative test. This happens in around 50% of patients with acute inflammation of the gallbladder^{(6, 7)}.

Sonographic Murphy’s sign

This is similar to how a Murphy’s sign is elicited. The ultrasonography probe is placed over the area of gallbladder. The painful reaction or catch of breathe occurs when the probe touched the gallbladder ⁽⁵⁾. Then the test is called a positive sonographic Murphy’s sign, which occurs in acute cholecystitis.

The test may become negative if the inflammation has caused the necrosis of the walls of the gallbladder ⁽⁸⁾.

Other terms that may be confused with ‘Murphy’s sign’

Murphy’s triad

Murphy’s triad is related to acute appendicitis (inflammation of the vermiform appendix) and not to acute cholecystitis. The triad includes abdominal pain with vomiting and fever⁽⁹⁾.

Murphy’s sign test on hand

This is a test done on hand to diagnose dislocation of the lunate (a bone on hand). When the lunate is fractured, this sign becomes positive.

The patient is asked to make a fist with the suspected hand. The middle knuckle is compared with the neighbouring knuckles to see if they are on the same level. If they are on the same level, the test becomes positive and dislocation of lunate is diagnosed.⁽¹⁰⁾

Image 6:  Murphy’s sign in this case is negative as you can see the middle knuckle is not at the same level of its neighbours.

Murphy’s punch/ sign

This test is done to check if any infection or inflammation (pyelonephritis, hydronephrosis/ obstruction etc) is present in the kidneys. Jabbing thrusts with the heel of a closed fist over the junction of 12th vertebra and rib, elicits pain or tenderness, in cases of kidney infections or inflammations making a Murphy’s punch positive.

Image 7: A picture depicting Murphy’s punch test.

Other features in acute cholecystitis

Murphy’s sign is performed and observed by the examiner. But what else could indicate acute cholecystitis? The patients with acute cholecystitis are generally lying with care that no movement occurs.

This is because, movement aggravates pain. Abdomen may show guarding. Fever and tachycardia can be seen. Features of peritonitis or obstructions may be seen in cases with complications⁽⁴⁾.

Differential diagnosis of pain in right upper quadrant

For a complete list and details of pain in right upper quadrant, please click here (Link to article “Abdominal Pain”). A lot of other conditions may resemble the pain of acute cholecystitis. They may include⁽⁴⁾

• Intra-abdominal abscess
• Irritable bowel disease
• Visceral perforations
• Right kidney disease (See: Kidney Pain)
• Right sided pneumonia
• Fitz-Hugh-Curtis syndrome
• Ischemic heart disease
• Peptic ulcer disease
• Dysfunction of sphincter of Oddi
• Appendicitis
• Acute pancreatitis
• Mesenteric ischemia
• Budd-Chiari syndrome
• Cholelithiasis

Diagnosis

History of pain with associated symptoms such as fever, nausea and vomiting may be the complaints with which a patient of acute cholecystitis may present in the emergency. Physical examination may show Murphy’s sign positive.

To confirm the diagnosis of acute cholecystitis, further investigations and imaging will have to be done⁽⁴⁾.

Blood check will show general features of inflammation. Imaging studies can include ultrasonography, Cholescintigraphy and in some cases CT scan.

Complications of Cholecystitis

Complications are a common scenario in case of cholecystitis. They may include gangrene or perforation of the gallbladder. Fistula formation between the gallbladder and intestine is also common. Emphysematous cholecystitis can also occur in some cases ⁽⁴⁾.

References:

1. https://medical-dictionary.thefreedictionary.com/Murphy%27s+sign
2. https://en.wikipedia.org/wiki/Murphy%27s_sign
3. http://aibolita.com/sundries/8173-surface-anatomy-and-surface-markings.html
4. https://www.uptodate.com/contents/acute-cholecystitis-pathogenesis-clinical-features-and-diagnosis
5. https://www.researchgate.net/publication/230820198_Murphy’s_sign_of_cholecystitis-_a_brief_revisit
6. http://www.fpnotebook.com/surgery/exam/MrphySgn.htm
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429769/
8. http://www.ultrasoundtraining.com/acuteCholecys.htm
9. https://en.wikipedia.org/wiki/Murphy%27s_triad
10. http://ahn.mnsu.edu/athletictraining/spata/wristhandfingermodule/specialtests.html
11. https://medisavvy.com/murphys-punch-sign/