Murphy’s sign

Description

Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive.

Note: Murphy originally described his sign as ‘deep grip’ palpation under the right costal margin with the patient upright in a seated position on deep inspiration. Naunyn’s sign and Moynihan’s modified sign requires the patient to be supine with a more considered palpatory approach, more akin to modern textbook descriptions of Murphy’s sign.

1896 – Bernhard Naunyn (1839 – 1925) in his treatise on cholelithiasis described clinical examination for gallstones with palpation in the right upper quadrant on inspiration and comparing right and left hypochondria.

Naunyn’s method of palpation was published 7 years before that of John B. Murphy (1857 – 1916) and bears the closest resemblance to the clinical examination skill employed today.

If the liver is swollen as the result of the attack (i.e., recently) the organ is always more or less tender, and often very acutely so; but frequently it is tender without being swollen. In such cases it is found that pain is induced when, during a deep inspiration, pressure is made with the hand as far upwards as possible beneath the right costal border. At the moment when the liver impinges upon the tips of the fingers the patient experiences a deep-seated pain which sometimes radiates over the entire hepatic region and on to the epigastrium. By no means rarely, however, the tenderness of the liver is only manifested by tension of the muscles of the anterior abdominal wall on the right side, and in such cases the difference in tension of the right and left side respectively is best observed in the rectus abdominis.

1903 – John B. Murphy (1857 – 1916) described his clinical examination sign in patients with acute cholecystitis. Murphy examined the sitting patient from behind with fingers gripped under the right costal margin. Pain elicited at the height of inspiration evokes a positive test.

The most characteristic and constant sign of gall-bladder hypersensitiveness is the inability of the patient to take a full, deep inspiration, when the physician’s fingers are hooked up deep beneath the right costal arch below the hepatic margin. The diaphragm forces the liver down until the sensitive gall-bladder reaches the examining fingers, when the inspiration suddenly ceases as though it had been shut off. I have never found, this sign absent in a calculous or infectious case of gall-bladder, or duct disease.

Murphy 1903: 827-828

Murphy’s Hammer Stroke Percussion Test – Murphy also described a perpendicular percussion technique for evaluation of the inflamed gallbladder

1905 – Berkeley Moynihan (1865 – 1936) acknowledged Murphy’s 1903 description of right upper quadrant interrogation in the upright patient with fingers gripped under the lower right anterior costal margin. He also took into account Naunyn’s 1896 description of right upper quadrant examination on inspiration.

I have found the simplest method of eliciting the pressure signs to be this: While the surgeon sits on the edge of the couch, to the right of the patient, the left hand is laid over the lower part of the right side of the patient’s chest, so that the thumb lies along the rib-margin; as a deep breath is taken the thumb is pressed upwards towards the under surface of the liver.

Moynihan 1905

Clinical Validation

Note: Validation of Murphy’s sign has been attempted using the 1896 Naunyn original description of Murphy’s sign, rather than Murphy’s 1903 description of ‘deep grip palpation‘ or ‘Hammer stroke percussion technique‘

1996 – Singer et al found the presence of Murphy’s sign to be both sensitive (97.2%) and highly predictive (93.3%) of a positive hepatobiliary scintigraphy in patients with suspected acute cholecystitis.

1996 – Adedeji et al reviewed Murphy’s Sign and advised it should be used with caution in elderly patients. A positive sign is useful, however a negative sign is not reliable to rule out acute cholecystitis and further diagnostic tests should be instigated. They found

• The 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

Of note: The surgical community has long recognised that the real usefulness of the sign is in the non-acute patient where there is no tenderness.

The sonographic Murphy’s sign

Sherman et al (1980) and Ralls et al (1982) evaluated sonographic Murphy’s sign. The sonographer asks if the pain is worse than anywhere else when pressing directly over the gall bladder. The technique does not rely on an involuntary reaction, and the patient holds his or her breath.

Of the 219 patients included, 46 had proven acute cholecystitis and 173 had no evidence of acute cholecystitis. The sonographic Murphy sign was positive in 29/46 patients with acute cholecystitis. The
overall accuracy was 87.2%; sensitivity 63%; specificity was 93.6%. The predictive value of a positive sonographic Murphy sign was 72.5%.

Associated Persons

• Bernhard Naunyn (1839-1925)
• John Benjamin Murphy (1857-1916)
• Berkeley George Andrew Moynihan (1865-1936)

Alternative names

• Murphy Sign
• Moynihan’s sign; Moynihan’s modification
• Naunyn’s sign
• Sonographic Murphy’s sign

References

Original articles

• Naunyn B. A treatise on cholelithiasis. London: The New Sydenham Society 1896
• Murphy JB. The diagnosis of Gall-stones. The Medical News (London). 1903; 82(2): 825-883
• Moynihan B. Gall-stones and their surgical treatment. 1905: 150-151
• Murphy JB. Gallstone disease and its relation to intestinal obstruction. Illinois Medical Journal. 1910; 18: 272-280
• Murphy JB. 5 diagnostic methods of John B, Murphy. The Surgical Clinics of John B. Murphy, 1912; 1(1): 459-466
• Murphy, JB. Cholelithiasis. The Surgical Clinics of John B. Murphy, 1912; 1(1): 417-428

Review articles

• Sherman M, Ralls PW, Quinn M, Halls J, Keats JB. Intravenous cholangiography and sonography in acute cholecystitis: prospective evaluation. AJR Am J Roentgenol. 1980 Aug;135(2):311-3.
• Ralls PW, Halls J, Lapin SA, Quinn MF, Morris UL, Boswell W. Prospective evaluation of the sonographic Murphy sign in suspected acute cholecystitis. J Clin Ultrasound. 1982 Mar;10(3):113-5
• Aldea PA, Meehan JP, Sternbach G. The acute abdomen and Murphy’s signs. J Emerg Med. 1986;4(1):57-63.
• 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(3): 267-72
• Adedeji OA, McAdam WA. Murphy’s sign, acute cholecystitis and elderly people. J R Coll Surg Edinb. 1996; 41(2): 88.
• Salati SA, al Khadi A. Murphy’s sign of cholecystitis– a brief revisit. Journal of Symptoms and Signs. 2012; 1(2): 53-56
• Jeans PL. Murphy’s sign. The Medical Journal of Australia, 2017; 206(3): 115–116.
• Cadogan M. Murphy’s sign. Eponym A Day. Instagram