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Murphy's sign of cholecystitis– a brief revisit

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Abstract

Murphy's sign is one of the contributions made by a noted American surgeon J B Murphy about a century ago. This sign retains its validity even today. This article is written with the aim of reviewing Murphy's sign briefly.
Journal of Symptoms and Signs 2012; Volume 1, Number 2
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Clinical Signs
Murphy’s sign of cholecystitis– a brief revisit
Sajad Ahmad Salati, Azzam al Kadi
Department of Surgery, College of Medicine, Qassim University, Saudi Arabia.
Corresponding Author: Sajad Ahmad Salati, Department of Surgery, College of Medicine, Qassim University, Saudi Arabia. E-mail: docsajad@yahoo.co.in
Abstract
Murphy’s sign is one of the contributions made by a noted American surgeon J B Murphy about a century ago. This sign retains its validity
even today. This article is written with the aim of reviewing Murphy’s sign briefly.
Keywords: Murphy’s sign; cholecystitis; efficacy
Received: April 17, 2012; Accepted: May 29, 2012; Published online: June 3, 2012
Introduction
In the present era of evidence based medicine,
investigations form an important tool in clinician’s
armamentarium in reaching a diagnosis. However there
are certain clinical methods and signs which have
withstood the test of time and continue to be reliable and
cost effective diagnostic means. Murphy’s sign is one
such sign which has proven its efficacy over the last
hundred years in diagnosing cholecystitis.
Historical background
John Benjamin Murphy (1857–1916) was a extraordinary
american surgeon from the 1880s through the early 1900s.
He was well known for valuable contributions made in
the fields of vascular, urologic, neurologic, and
orthopaedic surgery. His name is associated with
multiple clinical signs like Murphy’s punch , Murphy’s
syndrome, Murphy’s sign test for metacarpals and
Murphy’s sign for gall bladder and instruments like
Murphy’s intestinal anastomosis buttons, Murphy-Lane
bone skid and Murphy drip. Murphy’s sign of gallbladder
was described in 1903 as hypersensitivity elicited by
deep palpation in the subcostal area when a patient with
presumed gallbladder disease takes a deep breath. This
sign is also called Naunyn’s Sign after the name of
Bernard Naunyn (1839–1925) who was professor of
clinical medicine successively at Berne and Strasburg
and described a similar sign thirteen years before
Murphy.
Techniques of eliciting Murphy’s sign
Hammer stroke maneuver
As originally described by Murphy [1], the maneuver
entails percussion of the right midsubcostal region with
the bent middle finger of the left hand, using the right
hand to strike the dorsum of the left hand with
Murphy’s sign
hammer-like blows (Figure 1). This method is
uncommonly used nowadays but can be of value in obese
patients.
Deep grip palpation
Standing behind the patient, provided that the patient is
well enough to assume an upright posture, the right hand
of the examiner curls up under the costal margin at the tip
of the ninth rib and patient is requested to take a deep
breath (Figure 2). If the gallbladder is inflamed, the
patient will experience pain and catch the breath as the
gallbladder descends and contacts the palpating hand. If
the patient cannot assume upright posture, the sign can be
elicited in supine position.
Alternatively, instead of curling up the fingers of right
hand, the extended fingers may be used to apply
moderate pressure and palpate deeply (Figure 3) while
the patient is taking deep breath in upright or supine
posture [2].
Moynihan’s modification of eliciting
Murphy’s sign
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The left hand is placed on the patient’s lowermost right
anterior rib cage, so that your index finger is resting on
the most inferior rib. The extended left thumb is abducted
and rotated in opposition down and into the patient’s
belly while the patient is requested to take a deep breath.
The thumb is kept where it is, without pressing deeper.
When the inflamed gallbladder presses against your
thumb the patient will experience pain or tenderness
enough to halt inspiration (usually at the end of
inspiration). If this maneuver is repeated without pressing
in with the thumb and the patient can now complete a full
inspiration then Murphy’s sign is positive for acute
cholecystitis.
Negative Murphy’s sign
It is identified when the patient comfortably inspires a
deep breath. In this case, the diaphragm pushes the
non-inflamed gallbladder into the palpating hand without
causing any discomfort.
Significance of Murphy’s sign
A positive Murphy’s sign often indicates cholecystitis,
where as a negative Murphy’s sign may suggest
pyelonephritis, and ascending cholangitis.
Murphy’s sign
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Pitfalls while eliciting a Murphy’s sign
The patient may feel pain on inspiration on both sides of
the costal margin and may lead to false positive
Murphy’s sign if only right side is assessed. Hence if
positive sign is elicited on right side, the left side should
also be evaluated on similar lines.
Incorrect placement of the examiner’s fingers can lead to
false negative results. Hence knowledge of correct
method is mandatory before attempting to elicit
Murphy’s sign.
Efficacy of Murphy’s sign
The efficacy of Murphy’s sign has been evaluated in
multiple studies in recent years. Singer, et al. [3] in
1996 undertook a retrospective analysis of 100 patients
with suspected acute cholecystitis to assess the ability of
various clinical and laboratory parameters to predict the
results of hepatobiliary scintigraphy (HBS). 53 patients
had a positive HBS, and 47 had a negative HBS. The
presence of Murphy's sign was both sensitive (97.2%)
and highly predictive (93.3%) of a positive HBS but was
not documented in 35 cases. No other variable was found
to be helpful in predicting the results of HBS. However,
Adedeji and McAdam [4] found Murphy’s sign to be less
reliable in elderly patients. They retrospectively assessed
how the presence or absence of Murphy's sign affected
initial diagnosis of acute cholecystitis in elderly patients.
In the presence of Murphy's sign, diagnostic accuracy for
acute cholecystitis was 80% dropping to 34% when the
sign was negative. The positive predictive value of the
test in elderly people was 0.58, with a sensitivity of 0.48
and a specificity of 0.79. It was concluded that in elderly
patients, a positive Murphy's sign is useful, but a negative
sign should be intrepreted with caution and other
diagnostic tests be conducted. Navarro Fernandez JA, et
al. [5] in 2009 also found a significant correlation
between Murphy’s sign and acute cholecystitis.
Trowbridge RL, et al. [6] in 2003 undertook a Cochrane
review of 17 studies to determine if aspects of the history
and physical examination or basic laboratory testing
clearly identify patients who require diagnostic imaging
tests to rule in or rule out the diagnosis of acute
cholecystitis and found Murphy’s test to be useful
positive LR: 2.8; 95% confidence interval (CI): 0.8 to
8.6).
Sonographic Murphy’s sign
The sonographic Murphy’s sign is similar to the
Murphy’s sign but in this method, the examiners hand is
replaced by ultrasound transducer (Figure 5). The sign is
elicited by palpating the right subcostal area using an
ultrasound transducer while the patient is requested to
inspire deeply. The ultrasound visualises the gallbladder
and confirms the origin of arrest in inspiration and pain
objectively when the organ is being pushed.
Efficacy of sonographic Murphy’s sign
Multiple studies have proven the efficacy of sonographic
Murphy’s sign. Ralls and colleagues [7] reviewed 497
patients of suspected acute cholecystitis and found that
98.8% of the patients in their series had a positive
ultrasonographic Murphy’s sign, making it a useful
diagnostic test. They further demonstrated that a
combination of gallstones and a positive Murphy’s sign
had a positive predictive value of 92.2% for acute
cholecystitis, while the absence of gallstones together
with a negative Murphy’s sign had a 95% negative
predictive value. Bree RL[8] evaluated 200 patients of
suspected acute cholecystitis and found that the
sensitivity of the sonographic Murphy sign in acute
cholecystitis was 86% with a specificity of 35%, positive
predictive value of 43%, and negative predictive value of
82%. The combination of the Murphy sign accompanied
by gallstones yielded a specificity of 77%. However Bree
RL found that this sign unreliable in separating acute
from chronic cholecystitis due to the large number of
false positives, and only moderate improvement in
specificity when accompanied by gallstones. Kendall J
L and Shimp R J [9] found that emergency
physician-detected sonographic Murphy sign was highly
sensitive for diagnosing acute cholecystitis and stressed
upon further evaluation of this modality in emergency
rooms.
Conclusion
Murphy’s sign alongwith its sonographic variant is a
useful and cost effective tool for diagnosis of acute
cholecystitis and Dr John B Murphy deserves our thanks
for showing us this technique.
Murphy’s sign
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56
Acknowledgements
I express my gratitude to the patients (actual/simulated)
who allowed the use of images for academic reasons.
Disclosure
There is no conflict of interest.
References
1. Morgenstern L. J. B. Murphy, M.D. Of buttons and blows. Surg
Endosc. 1998; 12(4):359-360.
2. Urbano F L, Carrol M . Murphy’s sign. Hospital Practice 2000;
70:51-52
3. Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ.
Correlation among clinical, laboratory, and hepatobiliary scanning
findings in patients with suspected acute cholecystitis. Ann Emerg
Med 1996; 28:267–272.
4. Adedeji OA, McAdam WA. Murphy’s sign, acute cholecystitis
and elderly people. J R Coll Surg Edinb 1996; 41:88–89.
5. Navarro Fernandez JA, Tarraga Lopez PJ, Rodriguez Montes JA,
Lopez Cara MA. Validity of tests performed to diagnose acute
abdominal pain in patients admitted at an emergency department.
Rev Esp Enferm Dig. 2009; 101(9):610-618.
6. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient
have acute cholecystitis? JAMA. 2003; 289(1):80-86.
7. Ralls PW, Colletti PM, Lapin SA, Chandrasoma P, Boswell WD
Jr, Ngo C, Radin DR, Halls JM. Real-time sonography in
suspected acute cholecystitis. Prospective evaluation of primary
and secondary signs. Radiology 1985; 155:767-771.
8. Bree RL. Further observations on the usefulness of the
sonographic Murphy sign in the evaluation of suspected acute
cholecystitis. J Clin Ultrasound. 1995; 23(3):169-172.
9. Kendall JL, Shimp RJ. Performance and interpretation of focused
right upper quadrant ultrasound by emergency physicians. J
Emerg Med. 2001; 21(1):7-13.
Copyright: 2012 © Sajad Ahmad Salati, et al. This is an Open
Access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the
original work is properly cited.
... Investigations are a crucial part of a clinician's toolkit in today's evidence-based medicine age. These techniques and indicators have been around for a long time and are trustworthy and affordable (Salati & al Kadi, 2012). Over the past century, the efficiency of Murphy's sign in the diagnosis of cholecystitis has been shown. ...
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Of buttons and blows
  • L J B Morgenstern
  • M D Murphy
Morgenstern L. J. B. Murphy, M.D. Of buttons and blows. Surg Endosc. 1998; 12(4):359-360.