Murphy's sign is seen in acute or chronic cases or cholecystitis
Reading File
Finding Sources
Murphy's Sign - Acute Cholecystitis
Murphy's sign is classically associated with ACUTE cholecystitis, not chronic.
What Is Murphy's Sign?
To elicit it, the examiner places their fingers under the right costal margin (over the gallbladder fossa) and asks the patient to take a deep breath. As the inflamed gallbladder descends on inspiration and contacts the examiner's fingers, the patient experiences sharp pain and abruptly stops inspiring (inspiratory arrest). This positive response is Murphy's sign.
Why Acute, Not Chronic?
- In acute cholecystitis, the gallbladder wall is acutely inflamed, edematous, and tender - direct compression reproduces significant pain.
- In chronic cholecystitis, the inflammation is low-grade and the gallbladder wall is fibrotic/thickened over time. The gallbladder is not acutely tender to palpation, so Murphy's sign is typically absent or negative.
Sonographic Murphy's Sign
A related finding used in ultrasound diagnosis is the sonographic Murphy's sign - maximal tenderness elicited when the ultrasound probe is pressed directly over the sonographically identified gallbladder. When combined with the presence of gallstones, it has a positive predictive value of ~92% for acute cholecystitis (Tintinalli's Emergency Medicine).
Important Caveats
Murphy's sign can be falsely negative in acute cholecystitis in certain situations:
- Gangrenous cholecystitis (necrosis of the wall destroys stretch receptors)
- Elderly patients or those with diabetes (blunted pain response)
- Gallbladder perforation (relieves pressure on the wall, causing temporary pain relief)
Summary Table
| Feature | Acute Cholecystitis | Chronic Cholecystitis |
|---|---|---|
| Murphy's Sign | Positive | Negative |
| Pain onset | Sudden, severe | Recurrent, dull |
| Fever/leukocytosis | Usually present | Usually absent |
| Gallbladder wall | Acutely inflamed | Fibrotic, thickened |
Bottom line: Murphy's sign = acute cholecystitis. Its absence does not rule out acute cholecystitis (especially in elderly/diabetic patients or gangrenous disease), but its presence is a strong clinical indicator.
- Tintinalli's Emergency Medicine, Clinical Gastrointestinal Endoscopy 3e, Yamada's Textbook of Gastroenterology 7e
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