Murphy’s sign is a clinical test used primarily in the diagnosis of acute cholecystitis, which is the inflammation of the gallbladder. It is named after American surgeon John Benjamin Murphy. This test is an important diagnostic tool in the evaluation of patients with suspected gallbladder disease. In this comprehensive blog post, we will explore the nature of Murphy’s sign, its diagnostic utility, the underlying causes of a positive Murphy’s sign, and its relevance in clinical practice. We will also address frequently asked questions and provide external resources for further reading.
What is Murphy’s Sign?
Murphy’s sign is a physical examination maneuver used to detect gallbladder inflammation. It involves palpating the right upper quadrant of the abdomen and asking the patient to take a deep breath. A positive Murphy’s sign occurs when the patient experiences pain and abruptly stops inhaling due to the discomfort caused by the inflamed gallbladder being pushed against the examining fingers.
How to Perform Murphy’s Sign
- Patient Position: Have the patient lie supine (on their back) with knees slightly bent to relax the abdominal muscles.
- Examiner Position: The examiner stands to the right of the patient.
- Palpation: Place your fingers or the edge of your hand under the right costal margin (below the rib cage) where the gallbladder is located.
- Deep Breath: Ask the patient to take a deep breath.
- Observation: Observe for any sharp pain that causes the patient to halt their inhalation.
A positive Murphy’s sign is indicated by the patient’s sudden stopping of the breath due to pain during the deep inhalation.
Diagnostic Utility of Murphy’s Sign
Murphy’s sign is particularly useful in the diagnosis of acute cholecystitis. Acute cholecystitis is often caused by gallstones blocking the cystic duct, leading to gallbladder inflammation. Identifying a positive Murphy’s sign can help differentiate acute cholecystitis from other causes of abdominal pain.
Sensitivity and Specificity
Murphy’s sign has varying sensitivity and specificity for diagnosing acute cholecystitis:
- Sensitivity: Approximately 65-87%
- Specificity: Approximately 48-79%
These values indicate that while Murphy’s sign is a helpful diagnostic tool, it should not be solely relied upon. Additional diagnostic methods, such as imaging studies and laboratory tests, are necessary to confirm the diagnosis.
Causes of a Positive Murphy’s Sign
A positive Murphy’s sign is most commonly associated with acute cholecystitis. However, other conditions can also cause right upper quadrant pain and should be considered in the differential diagnosis.
Acute Cholecystitis
Acute cholecystitis is the most common cause of a positive Murphy’s sign. It occurs when a gallstone obstructs the cystic duct, leading to gallbladder inflammation. Symptoms include severe right upper quadrant pain, fever, nausea, and vomiting.
Other Causes
- Chronic Cholecystitis: Chronic inflammation of the gallbladder, often due to recurrent gallstone obstruction, can occasionally present with a positive Murphy’s sign.
- Biliary Colic: Transient gallstone obstruction can cause pain but typically does not lead to a positive Murphy’s sign unless inflammation develops.
- Pancreatitis: Inflammation of the pancreas, particularly when affecting the head of the pancreas, can mimic gallbladder pain.
- Hepatitis: Liver inflammation can cause right upper quadrant pain, though Murphy’s sign is usually negative.
- Peptic Ulcer Disease: Ulcers in the stomach or duodenum can cause upper abdominal pain but typically do not produce a positive Murphy’s sign.
Clinical Relevance
Murphy’s sign remains an important clinical tool for evaluating patients with suspected gallbladder disease. However, it should be used in conjunction with other diagnostic methods to ensure accurate diagnosis and appropriate management.
Diagnostic Approach
- History and Physical Examination: Assess the patient’s history, including the nature of the pain, associated symptoms, and risk factors for gallbladder disease.
- Murphy’s Sign: Perform Murphy’s sign as part of the physical examination to assess for gallbladder inflammation.
- Laboratory Tests: Order blood tests, including liver function tests, complete blood count, and pancreatic enzymes, to evaluate for infection and inflammation.
- Imaging Studies: Utilize ultrasound as the primary imaging modality to visualize gallstones, gallbladder wall thickening, and pericholecystic fluid. Other imaging modalities, such as CT scan or HIDA scan, may be used if the diagnosis is unclear.
Management
Management of a positive Murphy’s sign depends on the underlying cause:
- Acute Cholecystitis: Typically requires hospitalization, intravenous antibiotics, and pain management. Surgical removal of the gallbladder (cholecystectomy) is usually recommended.
- Chronic Cholecystitis: May also require cholecystectomy, particularly if symptoms are recurrent or severe.
- Other Causes: Treatment will depend on the specific condition, such as medical management for peptic ulcer disease or supportive care for pancreatitis.
External Links for Further Reading
FAQs About Murphy’s Sign
1. What does a positive Murphy’s sign indicate?
A positive Murphy’s sign indicates the presence of gallbladder inflammation, most commonly due to acute cholecystitis. It is identified when the patient experiences pain and abruptly stops inhaling during a deep breath while the examiner palpates the right upper quadrant.
2. Can Murphy’s sign be negative in acute cholecystitis?
Yes, Murphy’s sign can be negative in some cases of acute cholecystitis, particularly if the inflammation is mild or if the gallbladder is not directly irritated during the examination. Additional diagnostic methods are needed to confirm the diagnosis.
3. How reliable is Murphy’s sign for diagnosing gallbladder disease?
Murphy’s sign is a useful diagnostic tool but has variable sensitivity and specificity. It should be used as part of a comprehensive evaluation, including history, physical examination, laboratory tests, and imaging studies, to accurately diagnose gallbladder disease.
4. Are there any conditions that can mimic a positive Murphy’s sign?
Yes, other conditions such as pancreatitis, hepatitis, and peptic ulcer disease can cause right upper quadrant pain but typically do not produce a positive Murphy’s sign. Differential diagnosis is important to identify the correct underlying cause.
5. What are the next steps if Murphy’s sign is positive?
If Murphy’s sign is positive, further evaluation with laboratory tests and imaging studies, such as ultrasound, is recommended to confirm the diagnosis of gallbladder disease and determine the appropriate management plan.
Conclusion
Murphy’s sign is a valuable clinical test used in the diagnosis of gallbladder inflammation, particularly acute cholecystitis. Understanding its diagnostic utility, proper execution, and the underlying causes of a positive Murphy’s sign can help healthcare professionals accurately diagnose and manage patients with suspected gallbladder disease. While Murphy’s sign is a useful tool, it should always be used in conjunction with other diagnostic methods to ensure a comprehensive evaluation and appropriate treatment.
