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.
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.
Shows the surgeons hands hooked under the costal arch to determine the sensitiveness of the gallbladder. The patient cannot inspire against the pressure with an acutely inflamed or distended gall-bladder – Murphy 1910 Murphy’s Hammer Stroke Percussion Test – Murphy also described a perpendicular percussion technique for evaluation of the inflamed gallbladder Fig 2; Shows the hand elevated, with the middle finger flexed perpendicularly at the tip of the ninth costal cartilage. Fig 3; Shows the finger struck with the right hand when the patient is in deep inspiration. This causes great pain if the gall-bladder is distended or inflamed. Murphy 1910 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.
Moynihan sign 1905: 151-152 Clinical ValidationNote: 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
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
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Cite this article as: Mike Cadogan and Michael Leith, "Murphy’s sign," In: LITFL - Life in the FastLane, Accessed on September 29, 2022, https://litfl.com/murphys-sign/. the names behind the name
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