Murphy Sign: What is it? Technique, Exam, Predictive Value and History

In medicine, it refers to a maneuver during a physical examination as part of the abdominal examination and a finding caused on ultrasound.

The signs and symptoms of an acute abdomen in elderly patients are not so classic or specific (which may explain differences in sensitivity and specificity).

In elderly patients, a positive Murphy sign is useful, but a negative sign is not exclusive and other diagnostic tests should be performed immediately.

The ultrasound Murphy sign is defined as maximum abdominal sensitivity of the ultrasound probe pressure on the visualized gallbladder

The ultrasound Murphy sign is a sign of local inflammation around the gallbladder along with pain, tenderness or mass in the right upper quadrant.

It is one of the most important echographic signs of cholecystitis and when combined with the presence or absence of cholelithiasis has a high positive and negative predictive value, respectively.

It is useful to differentiate pain in the right upper quadrant. In general, it is positive in cholecystitis, but negative in choledocholithiasis, pyelonephritis and ascending cholangitis.

Murphy’s sign technique

Have the patient lie in the supine position on the exam table

Place your left hand, with your fingers pointing towards the midline, on the patient’s lower right anterior thoracic cage, so that your index finger rests on the lowermost rib

Extend your left thumb and push it towards the patient’s abdomen and hold it.

Note : do not lean on the patient’s rib cage.

Ask the patient to breathe deeply.

Note : you should feel that the rib cage moves toward you during inspiration.

Consider the patient’s breathing and the degree of sensitivity.

Repeat the test with a placebo maneuver placing the hand in the same position but do not push with the thumb.

Note if the patient can complete a complete inspiration.

During the physical examination

Classically, Murphy’s sign is tested during an abdominal examination; it is done by asking the patient to exhale and then gently place the hand below the costal margin on the right side in the middle clavicular line (the approximate location of the gallbladder).

The patient is instructed to inspire. Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves downward (and the lungs expand).

If the patient stops breathing (since the gallbladder is sensitive and, when moving down, comes into contact with the examiner’s fingers) and winces when breathing, the test is considered positive. For the test to be considered negative, the same maneuver should not cause pain when performed on the left side.

Predictive value

Positive : the patient experiences sufficient pain / sensitivity to cause an abrupt halt in inspiration (usually occurs towards the end of inspiration) and acute cholecystitis is suspected .

Negative : the patient can complete a complete inspiration without significant pain / sensitivity.

The Murphy sign has a high sensitivity and a negative predictive value; although, the specificity is not high. However, in the elderly the sensitivity is markedly lower; A negative Murphy sign in an elderly person is not useful to rule out cholecystitis if other tests and medical history suggest the diagnosis.

The Murphy sign may be less accurate in elderly patients because up to 25% of patients older than 60 years with cholecystitis lack any abdominal sensitivity. Although most of these patients have abdominal pain, some have an altered mental state and also lack this symptom.

History of the Murphy sign

It is named after the American physician John Benjamin Murphy (1857-1916), a prominent surgeon in Chicago from the 1880s to the early 1900s, who first described hypersensitivity to deep palpation in the subcostal area when a patient with chronic the vesicle breathes deep.

There is also a sonographic Murphy sign, triggered during ultrasound of the right upper quadrant, which is simply the finding of maximum sensitivity over the gallbladder.

Studies of this sign in patients with pain in the right upper quadrant reveal a much better diagnostic accuracy than conventional palpation: sensitivity 63%, specificity 94%, positive LR = 9.9 and negative LR = 0.4.78.

The superior precision of this sign, which also depends on the palpation of the abdominal wall, suggests that the poorer precision of conventional palpation is due to the difficulty in accurately locating the position of the gallbladder.

In patients with a pyogenic liver abscess, the presence of Murphy’s sign increases the likelihood of sepsis of the associated biliary tract (sensitivity 32%, specificity 88%, positive LR = 2.8, negative LR not significant).