John B. Murphy (1867-1916) was a prominent Chicago surgeon well known for his thoracic procedures used in the treatment of tuberculosis. He made valuable contributions to the sciences of thoracic, vascular, urologic and orthopedic surgery. In 1903, he described the physical exam maneuver useful in the diagnosis of cholecystitis that we now refer to as Murphy's sign. It is one of at least five physical signs that bear his name today. To test for Murphy's sign, palpate the patient in the area of the gallbladder (approximately where the lateral border of the rectus muscle meets the costal margin) and ask the patient to take a deep breath. A positive Murphy's sign is a sudden arrest during inspiration caused by the diaphragmatic displacement of the liver and inflamed gallbladder (1).
In examining the accuracy of Murphy's sign in the diagnosis of acute cholecystitis, it is first important to differentiate the bedside Murphy's sign from a sonographic Murphy's sign. A sonographic Murphy's sign is performed using ultrasound guidance to ensure that the gallbladder is palpated. This radiographic sign is far more accurate than the bedside sign. The predictive value of a positive sign was 72.5%, while the predictive value of a negative sign was 90.5%. From a clinical perspective, a negative sonographic Murphy's sign means that the patient has a low likelihood (<10%) of having acute cholecystitis while the presence of a sonographic Murphy's sign is strongly suggestive (>70%) of acute cholecystitis.(2) The bedside sign also demonstrates a high sensitivity (>97%) but a much lower specificity (48%) for acute cholecystitis. (3)
Because of its high sensitivity, the abscence of a bedside Murphy's sign argues strongly against cholecystitis, but because of its relatively poor specificity, the presence of a bedside Murphy's sign is not diagnostic of cholecystitis. The presence of Murphy's sign as part of a clinical picture suggestive of cholecystitis should prompt the physician to further evaluate the gall bladder with imaging studies such as ultrasonography or radionucleotide scanning.
1) Bickley LS, Hoekelman RA. Bate's guide to physical examination and history taking, 7th Ed. Lippincott Williams & Wilkens. Philadelphia: 1999.