Definition

Murphy's Sign is the cessation of inspiration (inspiratory arrest) caused by pain when the examiner's hand impinges on the inflamed gallbladder. It is the hallmark sign of Acute Cholecystitis.

Sensitivity & Specificity

• Sensitivity: 97% (If negative, cholecystitis is unlikely).
• Specificity: 48% (Positive in other RUQ pathology).
• Sonographic Murphy's Sign: Elicited with the ultrasound probe. Sensitivity is even higher (99%).

The "False" Murphy's

• Elderly: May have pathologically thick-walled gallbladder but no pain (Gangrenous cholecystitis).
• Analgesia: Opioids mask the sign.
• Anatomical Variance: Situs inversus (Left sided liver).

Preparation

1. Position: Patient supine, arms by sides. Abdomen exposed from xiphisternum to symphysis pubis.
2. State: Palpate the Left Upper Quadrant first (control).
3. Instruction: "I want you to take a deep breath in through your mouth."

The Manoeuvre

1. Place the left hand flat on the lower rib cage.
2. Place the tips of the right fingers (or thumb) just below the costal margin in the mid-clavicular line (Gallbladder territory).
3. Ask the patient to breathe in deeply.
4. As the diaphragm descends, the liver and gallbladder move downwards towards your static fingers.
5. Positive Sign: The patient stops breathing mid-breath (Inspiratory Arrest) due to sharp pain as the inflamed gallbladder hits your fingers.
   • Note: Pain alone is NOT Murphy's sign. It must be an arrest of inspiration.

If Murphy's is Positive, but CT shows normal gallbladder:

1. Hepatitis: Glisson's capsule stretch.
2. Fitz-Hugh-Curtis Syndrome: Gonorrhoeal Peri-hepatitis (Violin string adhesions).
3. Right Lower Lobe Pneumonia: Referred pain.
4. Peptic Ulcer Disease: Duodenal ulcer perforation.
5. Pyelonephritis: Right kidney lies posterior to liver.
6. Sub-phrenic Abscess.

1. Perforation

• Localised (Abscess) or Free (Generalised Peritonitis).
• High mortality (30%).

2. Empyema

• Gallbladder fills with pus. Toxic patient. Septic shock.

3. Emphysematous Cholecystitis

• Gas-forming organisms (Clostridium perfringens).
• Air in gallbladder wall on CT.
• Seen in Diabetics. Surgical Emergency.

4. Gallstone Ileus

• Fistula forms between gallbladder and duodenum.
• Large stone passes into bowel -> Obstructs Terminal Ileum.
• Rigler's Triad: Pneumobilia (Air in biliary tree) + Small Bowel Obstruction + Ectopic Stone.

The "Stormy Petrel of Surgery"

• Who: American surgeon, Chicago.
• Innovations:
  • Murphy's Button: A mechanical device for bowel anastomosis (Precursor to the stapler).
  • Artificial Pneumothorax: For TB treatment.
  • Vascular Suture: First successful end-to-end anastomosis of human arteries.
• Personality: Brilliant but controversial. Accused of stealing patients. A captivating teacher.
• Quote: "Diagnosis is the preamble of the surgical charter."

Tokyo Guidelines 2018 (TG18)

The global standard for acute cholecystitis.

• Grade I (Mild): Healthy patient. Lap Chole ASAP.
• Grade II (Moderate): WCC >18, Palpable mass, Duration >72h. Early Lap Chole if experienced surgeon.
• Grade III (Severe): Organ failure (Hypotension, Renal, Resp). Treat organ failure first. Cholecystostomy drain.

Antibiotic Stewardship

• Routine post-op antibiotics are NOT required for Grade I/II if source control (removal) is achieved.

"I am going to press on your tummy under your ribs. It might be a bit tender. I need you to take a big breath in. If it hurts, just breathe out."

Explanation of Surgery: "We need to take the gallbladder out. It's an organ you can live without. We do it keyhole (4 small cuts). You usually go home the same day or next day. The main risk is damage to the bile duct, which is rare (1 in 500)."

• Acalculous Cholecystitis: Inflammation WTIHOUT stones. Seen in ICU/Trauma (biliary stasis). High mortality.
• Biliary Colic: Temporary obstruction. Pain <6 hours. Normal LFT/Inflammatory markers.
• Cholangitis: Infection of the Bile Duct (Charcot's Triad).
• Choledocholithiasis: Stones in the Common Bile Duct.
• Cholelithiasis: Stones in the Gallbladder (Asymptomatic).
• Critical View of Safety: Surgical identification of Cystic Duct and Artery to prevent bile duct injury.
• Mirizzi Syndrome: Stone in cystic duct compressing hepatic duct.
• Saint's Triad: Hiatus Hernia + Diverticulosis + Gallstones.

Why is Ultrasound the Gold Standard for Gallstones?

1. Acoustic Impedance

• Principle: Sound waves reflect when they hit an interface between tissues of different density.
• Gallstone: Very dense. Reflects ALL sound.
• Effect:
  • Hyperechoic: The stone itself is bright white (Strong reflection).
  • Acoustic Shadowing: There is a black streak behind the stone because no sound waves can pass through it. This is the diagnostic sign.

2. Sludge vs Stone

• Sludge: Thick bile (microlithiasis).
  • Appearance: Low level echoes. Layers with gravity. NO shadowing.
• Stone:
  • Appearance: Bright. Shadowing. Moves when patient rolls over ("Rolling Stone").

3. Wall Thickening

• Normal: <3mm.
• Cholecystitis: >3mm (Edema).
• False Positives: Hepatic failure (low albumin), Cardiac failure, Ascites. (The gallbladder is like a sponge, it swells with systemic edema).

The Rule of 3s: The Portal Triad (entering the liver) consists of:

1. Portal Vein: Posterior. (Sources blood from gut).
2. Hepatic Artery: Medial. (Oxygenated blood).
3. Bile Duct: Lateral. (Draining bile).

Variations (The Surgeon's Nightmare):

• Moynihan's Hump: A tortuous Hepatic Artery that "humps" down into Calot's triangle. If mistaken for the Cystic Artery -> Major arterial bleed or hepatic liver necrosis.
• Short Cystic Duct: The Gallbladder drains directly into the CBD. Risk of clipping the CBD.

Nerves:

• C3,4,5 (Phrenic): Innervates diaphragm and gallbladder peritoneum.
• Referred Pain: Pain radiates to the Right Shoulder Tip (Kehr's Sign reference, though technically Kehr's is left/spleen, the mechanism is identical).

Case 1: The "Silent" Sepsis (Gangrenous Cholecystitis)

• Patient: 85M. Diabetic. Found confused on floor.
• Exam: Abdomen soft? No Murphy's sign.
• Bloods: CRP 300. Lactate 4.
• CT: Air in gallbladder wall. Gangrene.
• Mechanism: Ischaemia + Neuropathy = NO PAIN.
• Lesson: In the elderly diabetic, the abdomen can be silent despite catastrophe.

Case 2: The "Jaundiced" Stone (Choledocholithiasis)

• Patient: 40F. Colicky pain + Yellow eyes.
• Bloods: Bili 80. ALT 300. ALP 400.
• US: Dilated CBD (>8mm).
• Treatment:
  1. ERCP: Camera down throat -> Cut sphincter (Sphincterotomy) -> Drag stone out with basket.
  2. Lap Chole: Days later (to prevent recurrence).

• Acoustic Shadowing: The black shadow behind a stone on Ultrasound.
• Cholangiocarcinoma: Bile duct cancer. Painless jaundice + Palpable Gallbladder (Courvoisier's Law).
• Courvoisier's Law: "In the presence of jaundice, a palpable non-tender gallbladder is unlikely to be stones." (Implies Cancer).
• ERCP: Endoscopic Retrograde Cholangio-Pancreatography.
• HIDA: Hepatobiliary Iminodiacetic Acid scan.
• Lithogenic Bile: Bile prone to forming stones (High cholesterol, Low bile salts). 4Fs (Fair, Fat, Female, Forty).
• MRCP: Magnetic Resonance Cholangio-Pancreatography. (MRI of the biliary tree). Non-invasive alternative to ERCP.
• Ursodeoxycholic Acid: A drug that can dissolve small cholesterol stones (rarely used, takes years).

1. Yokoe M, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018.
2. Strasberg SM, et al. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995. (The "Critical View" Paper).
3. Gomi H, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018.
4. Murphy JB. The diagnosis of gall-stones. Med News. 1903.
5. Shea JA, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994.
6. Ahmed A, et al. Management of acute cholecystitis in the elderly. Br J Surg. 2019.
7. Sorensen P, et al. Laparoscopic cholecystectomy: a review of current practice. Surgy. 2015.
8. Goyal N. Surgical Anatomy of Calot's Triangle. Operative Surgery. 2024.
9. Royal College of Surgeons. Commissioning Guide: Gallstone Disease. 2016.
10. NICE CG188. Gallstone disease: diagnosis and management. 2014.

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