MURPHY'S SIGN: WHAT IT CONSISTS OF AND DISEASES - MEDICINE - 2025

The sign of Murphy is a semiológica evidence, usually surgical, abdominal pathology obtained through specific maneuvers. Although it is almost always related to pathologies of the gallbladder, some other diseases with incidence in the abdomen can manifest through this sign.

Murphy's sign, which may or may not be present depending on the patient's manifestations, is very easy to evaluate. Sustained pressure is applied to the right upper quadrant of the lying patient and asked to inhale deeply. If there is acute pain and sudden stoppage of breathing, it is considered positive.

It was described by the American physician John Benjamin Murphy, prominent abdominal and thoracic surgeon of the late 19th and early 20th centuries. In addition to this sign there are the Murphy button, the Murphy drip, the Murphy test and even surgical instruments such as Murphy-Lane's bone slider, all eponymous to the same man.

What does it consist of?

As previously mentioned, the technique for evaluating Murphy's sign is very simple. The patient is stripped of the garments that cover her trunk and lies on an evaluation table.

If abdominal surgical pathology is suspected, the clinical assessment scheme should be followed: first observation and then auscultation.

Once the first two steps of the physical examination have been completed, palpation is performed. With the tips of the fingers, the examiner presses firmly and steadily on the patient's right upper quadrant while prompting him to take a slow breath and hold it into the lungs.

If the Murphy sign is positive, during inspiration there will be a sudden cessation of breathing and an immediate painful sensation. The same procedure should be performed on the left side of the body to determine if the pathology causing abdominal pain is exclusive to a single organ or if it affects other viscera.

Positive Murphy sign diseases

Murphy's sign has a high sensitivity and an important negative predictive factor, but the specificity is low. What does this mean? This means that its absence practically rules out certain diseases, especially inflammation of the gallbladder, but its presence does not necessarily translate into acute cholecystitis.

It is understood that there are various pathologies capable of generating positive Murphy's sign, among which we have the following:

Acute cholecystitis

It is the disease associated with the Murphy sign par excellence. It is the acute inflammation of the gallbladder, a small pear-shaped organ located below the liver that contains bile (hence its name), a substance released in the small intestine that performs digestive functions.

Most cases are related to the presence of stones inside, but it is not the only cause of acute cholecystitis. Some infections and local tumors can cause inflammation of the gallbladder, either by reactive thickening of its walls or by obstruction of the bile outlet ducts.

The inflamed gallbladder is very tender to touch, but palpating it through clinical maneuvers is difficult. Hence, Dr. Murphy raised the idea of ​​"reaching" it more easily, changing its location and moving the surrounding tissues away, which is achieved with deep inspiration and movement of the liver with the hands.

Acute appendicitis

Although they are infrequent, certain cases of acute appendicitis - especially when it is in the infrahepatic region - can manifest a positive Murphy's sign.

These confusions can be dangerous due to misdiagnosis and unnecessary or rather late surgical intervention.

Viral hepatitis

Some cases of viral hepatitis, especially hepatitis A, can present with a positive Murphy's sign. This finding is due to the fact that the inflammation of the liver caused by the immune response against the virus can affect the gallbladder by contiguity, behaving as if it were acute cholecystitis.

Hepatomegaly

Increased liver volume can distend Glisson's capsule, the fibrous layer that covers the liver, and cause pain on handling.

Although it can be confused with a positive Murphy's sign, a proper assessment will determine that the characteristics of the pain are not exactly the same and that there are slight differences between these conditions.

Other vesicular pathologies

Perforation, gangrene or vesicular plastron, which can be complications of acute cholecystitis, have the Murphy sign among their clinical findings.

However, all the entities mentioned above are accompanied by a much more spectacular clinical picture, with an important touch on the general condition and symptoms of sepsis.

Rib fractures

Some rib injuries, with inflammation of the neurovascular bundle and even fractures, can present with a positive Murphy's sign.

It is not unusual for thoracoabdominal injuries to cause floating rib fractures, which due to their anatomical location can be confused with gallbladder pathologies.

Predictive value

Murphy's sign has a very important negative predictive value. This means that its absence rules out certain diseases out of the box, especially acute cholecystitis, although in some very specific patients - such as the elderly or diabetics - there may be controversy.

Gallstones (or gallstones) without inflammation as such, do not present with Murphy's sign. The same occurs with cysts of the common bile duct, a tube that drains bile from the gallbladder, which when present have many clinical manifestations similar to cholecystitis but without the characteristic Murphy's sign.

Murphy's sign ultrasound

Since ultrasound is currently one of the most widely used studies for the diagnosis of abdominal pathologies, it has been found that during the ultrasound a reaction very similar to the Murphy's sign that is generated manually during the physical examination can occur.

The technique complies with the same pathophysiological principles. The aim is to awaken the characteristic pain by exerting pressure on the right upper quadrant during inspiration, only it is not carried out with the hands but with the transducer of the ultrasound equipment.

The answer will be exactly the same: sudden stop of breathing and pain. Only the imaging doctor is authorized to write the presence of a positive Murphy ultrasound sign within the study findings, which will serve as much guidance to the treating surgeon.

References

1. Musana, Kenneth (2005). Murphy's Sign. Clinical Medicine & Research, 3 (3): 132.
2. Salyer, Steven W. (2007). Acute Surgical Abdominal Emergencies. Essential Emergency Medicine, Chapter 1, 1-36.
3. Garfunkel, Lynn C. (2007). Cholelithiasis, Cholecystitis & Choledochal Cysts. Pediatric Clinical Advisor, Second Edition, 113-114.
4. Motta Ramirez, Gaspar Alberto and Uscanga Carmona, Maria Celeste (2002). Murphy, Mc Burney and Giordano clinical points: Current value and its correlation with ultrasonography. Anales de Radiología México, 2: 409-416.
5. Friedman, AC et al. (2011). Sonography of Acute Cholecystitis: Murphy's Sign or Murphy's Law? Ultrasound in Medicine and Biology, 37 (8): 87.
6. Wikipedia (last edition 2018). Murphy's sign. Recovered from: en.wikipedia.org