Murphy's sign
Encyclopedia
In medicine
, Murphy's sign refers to a maneuver during a physical examination
as part of the abdominal examination
and a finding elicited in ultrasonography
. It is useful for differentiating
pain
in the right upper quadrant. Typically, it is positive in cholecystitis
or choledocholithiasis, but negative in pyelonephritis
and ascending cholangitis
.
; it is performed by asking the patient to breathe out and then gently placing the hand below the costal margin
on the right side at the mid-clavicular
line (the approximate location of the gallbladder
). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal
contents are pushed downward as the diaphragm moves down (and lung
s expand). If the patient stops breathing in (as the gallbladder is tender
and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive. A positive test also requires no pain on performing the maneuver on the patient's left hand side. Ultrasound imaging
can be used to ensure the hand is properly positioned over the gallbladder
; however, the specificity is not high. In the elderly the sensitivity is markedly lower; a negative Murphy's sign in an elderly person is not useful for ruling out cholecystitis if other tests and the clinical history suggest the diagnosis.
John Benjamin Murphy
(1857–1916), a prominent Chicago surgeon from the 1880s through the early 1900s, who first described the hypersensitivity to deep palpation in the subcostal area when a patient with gallbladder disease takes a deep breath.
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, Murphy's sign refers to a maneuver during a physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
as part of the abdominal examination
Abdominal examination
The abdominal exam, in medicine, is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology.The exam includes several parts:* Setting and preparation...
and a finding elicited in ultrasonography
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
. It is useful for differentiating
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
pain
Abdominal pain
Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...
in the right upper quadrant. Typically, it is positive in cholecystitis
Cholecystitis
-Signs and symptoms:Cholecystitis usually presents as a pain in the right upper quadrant. This is known as biliary colic. This is initially intermittent, but later usually presents as a constant, severe pain. During the initial stages, the pain may be felt in an area totally separate from the site...
or choledocholithiasis, but negative in pyelonephritis
Pyelonephritis
Pyelonephritis is an ascending urinary tract infection that has reached the pyelum or pelvis of the kidney. It is a form of nephritis that is also referred to as pyelitis...
and ascending cholangitis
Ascending cholangitis
Ascending cholangitis or acute cholangitis is an infection of the bile duct , usually caused by bacteria ascending from its junction with the duodenum...
.
During physical examination
Classically Murphy's sign is tested for during an abdominal examinationAbdominal examination
The abdominal exam, in medicine, is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology.The exam includes several parts:* Setting and preparation...
; it is performed by asking the patient to breathe out and then gently placing the hand below the costal margin
Costal margin
The costal margin, sometimes referred to as the costal arch, is the medial margin formed by the false ribs and one true rib -- specifically, from the seventh rib to the tenth rib....
on the right side at the mid-clavicular
Clavicle
In human anatomy, the clavicle or collar bone is a long bone of short length that serves as a strut between the scapula and the sternum. It is the only long bone in body that lies horizontally...
line (the approximate location of the gallbladder
Gallbladder
In vertebrates the gallbladder is a small organ that aids mainly in fat digestion and concentrates bile produced by the liver. In humans the loss of the gallbladder is usually easily tolerated....
). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal
Abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
contents are pushed downward as the diaphragm moves down (and lung
Lung
The lung is the essential respiration organ in many air-breathing animals, including most tetrapods, a few fish and a few snails. In mammals and the more complex life forms, the two lungs are located near the backbone on either side of the heart...
s expand). If the patient stops breathing in (as the gallbladder is tender
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive. A positive test also requires no pain on performing the maneuver on the patient's left hand side. Ultrasound imaging
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
can be used to ensure the hand is properly positioned over the gallbladder
Predictive value
Murphy's sign has a high sensitivity and negative predictive valueNegative predictive value
In statistics and diagnostic testing, the negative predictive value is a summary statistic used to describe the performance of a diagnostic testing procedure. It is defined as the proportion of subjects with a negative test result who are correctly diagnosed. A high NPV means that when the test...
; however, the specificity is not high. In the elderly the sensitivity is markedly lower; a negative Murphy's sign in an elderly person is not useful for ruling out cholecystitis if other tests and the clinical history suggest the diagnosis.
History
The sign is named for American physicianPhysician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
John Benjamin Murphy
John Benjamin Murphy
John Benjamin Murphy, born John Murphy , was an American physician and abdominal surgeon noted for advocating early surgical intervention in appendicitis appendectomy, and several eponyms: Murphy’s button, Murphy drip, Murphy’s punch, Murphy’s test, and Murphy-Lane bone skid...
(1857–1916), a prominent Chicago surgeon from the 1880s through the early 1900s, who first described the hypersensitivity to deep palpation in the subcostal area when a patient with gallbladder disease takes a deep breath.
See Also
- Courvoisier's lawCourvoisier's lawCourvoisier's law states that in the presence of an enlarged gallbladder which is nontender and accompanied with mild jaundice, the cause is unlikely to be gallstones. Usually, the term is used to describe the physical examination finding of the right-upper quadrant of the abdomen...
- when the gallbladder is palpable, painless jaundiceJaundiceJaundice is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae , and other mucous membranes caused by hyperbilirubinemia . This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid...
is unlikely to be related to gallstones. - Sonographic Murphy signSonographic Murphy signA Sonographic Murphy sign refers to a finding when performing diagnostic medical sonography. It is different from the Murphy sign found on physical examination, but both signs are associated with cholecystitis When the sonographer presses directly over the gallbladder, and the patient expresses...