Murphy sign

Murphy sign is elicited by placing fingers or hand beneath the right costal margin at the point where the lateral border of the rectus abdominis crosses the costal margin (approximately the location of the gallbladder), then asking the patient to take a deep breath. A positive sign occurs when the patient abruptly stops inspiration due to pain as the inflamed, tender gallbladder moves downward during diaphragmatic excursion and contacts the palpating hand. It reflects localized peritoneal irritation from an inflamed gallbladder, most commonly due to cholelithiasis obstructing the cystic duct leading to acute cholecystitis. Sensitivity is reported around 65-97% but specificity is lower (~48-79%), and the sign can be falsely negative in elderly or diabetic patients with blunted pain response, or in gangrenous cholecystitis where the gallbladder wall becomes necrotic and less reactive. Sonographic Murphy sign (pain elicited when the ultrasound probe compresses over the visualized gallbladder) is a more specific finding used during right upper quadrant ultrasound, which is the imaging modality of choice for cholecystitis. Clinically, Murphy sign is part of the presentation of acute cholecystitis, typically accompanied by right upper quadrant pain (often postprandial after fatty meals), fever, leukocytosis, and Boas sign referred pain to the right subscapular region. Differential diagnoses to consider include biliary colic (no fever/inflammation), choledocholithiasis, ascending cholangitis (Charcot triad/Reynolds pentad), and perforated peptic ulcer. Management of acute cholecystitis often involves IV fluids, antibiotics, and cholecystectomy (laparoscopic), timing depends on clinical stability.