JIBRAN MOHSINRESIDENT, SURGICAL UNIT I

SIMS / SERVICES HOSPITAL, LAHORE

MURPHY’S SIGN of cholecystitis/gallbladder: sign of acute or chronic cholecystitis?

John Benjamin Murphy (1857-1916)

• American physician and abdominal surgeon

• advocated early surgical intervention in appendicitis (appendectomy)

• and several eponyms

John Benjamin Murphy•  Mayo Clinic co-founder William James Mayo called him "the surgical genius of our generation“

• After he suffered from angina pectoris for several years, his death was attributed to aortitis.

• Two days prior to his death he correctly predicted the findings of his own autopsy: "I think the necropsy will show plaques in my aorta."

John Benjamin Murphy• Performed 1st biliary tract endoscopy (1912)

• 1st to do femoral artery anastomosis after gunshot injury (1896)

• 1st  to induce artificial immobilization and collapse of the lung (pneumothorax) in treatment of pulmonary tuberculosis (1898)

• pioneered bone grafting techniques

• innovator for surgical intervention for prostate cancer

• Pioneered end-to-end anastomosis of hollow viscera

John Benjamin MurphyEPONYMSCLINICAL

 Murphy’s (kidney) punch (sign)(test) -1884-USA(Pasternacki's sign-1888-Europe)(Goldflam's sign-1900-Poland)(Latin: succusio renalis)

Percussion/Punch tenderness at the costo-vertebral angle (CVAT)

In cases of perinephric abscess, pyelonephritis, renal stone, hemorrhagic fever with renal syndrome

Murphy’s syndrome Osteopathia striata-pigmentary dermopathy-white forelock syndrome

Murphy’s sign (test) for metacarpals

3rd MCP joint in line with adjacent MCP joints in fist

Lunate Dislocation

Murphy’s triad Pain vomiting Fever Acute appendicitis

John Benjamin MurphyEPONYMS

INSTRUMENTS

Murphy’s (intestinal anastomosis) Button

• mechanical device used for suture less anastomosis of the gallbladder to the duodenum (his preferred treatment for acute cholecystitis)

• equally suitable for intestinal anastomoses

credited as the forerunner of the modern end-to-end stapling instrument

 Murphy drip administration of fluids by proctoclysis in patients with peritonitis

Murphy-Lane bone skid

common commercial steel instrument used for femoral head procedures

Background• In 1903, Murphy described it as hypersensitivity

elicited by deep palpation in subcostal area when a patient with presumed gallbladder disease takes a deep breath

• Also called NAUNYN’S SIGN• Bernard Naunyn (1839-1925) German pathologist described

a similar sign 13 years before Murphy i.e. in 1890.

PRINCIPLE • Deep palpation of Right Hypochondrium/Subcostal region

• Due to intraperitoneal position of gallbladder, its moves with respiration

• During inspiration, diaphragm flattens, gallbladder along with liver moves downward

• Fundus of gallbladder protrudes through the inferior border of liver

• Visceral peritoneum covering the fundus touches the deeply pressed parietal peritoneum of anterior abdominal wall (similar to somatic component of acute appendicitis pain in RIF)

• Causing painful response (Positive Murphy’s sign) leading to sudden arrest of breathing/wince with a “catch” in the breath at peak of inspiration.( termed inspiratory arrest, described as “shutting off” of the inspiration)

Techniques of eliciting Murphy’s sign

• Hammer Stroke maneuver

• Deep grip palpation

• Deep palpation (Moynihan’s) technique

• Moynihan’s modification of eliciting Murphy’s sign

Techniques of eliciting Murphy’s sign

I. HAMMER STROKE MANEUVER

• Originally described by murphy

• Percussion at Gallbladder point

• Uncommonly used nowadays, but can be value in obese patients

Techniques of eliciting Murphy’s sign

II. DEEP GRIP PALPATION

• Standing behind patient (provided patient is well enough to assume an upright position)

• Right hand of examiner curls up under costal margin at tip of 9th rib and patient requested to take deep breath

• If inflamed gallbladder patient experience pain and catches breath as gallbladder descends and contacts parietal peritoneum of anterior abdominal wall under the palpating hand

• If patient can’t assume upright posture can be elicited in supine position

Techniques of eliciting Murphy’s sign

III. DEEP PALPATION (MOYNIHAN’s) TECHNIQUE

• Most commonly used method

• Extended fingers used to apply moderate pressure and palpate deeply while patient takes deep breath in upright (Murphy’s sign) or supine position (Moynihan’s sign).

Techniques of eliciting Murphy’s sign

IV. MOYNIHAN’S MODIFICATION OF ELICITING MURPHY’S SIGN

• Left hand placed on patient’s lowermost right anterior ribcage i.e. index finger resting on most inferior rib

• Extended left thumb is abducted and rotated in opposition down and into patient’s belly while patient takes deep breath.

• Thumb kept static without pressing deeper

Techniques of eliciting Murphy’s sign

IV. MOYNIHAN’S MODIFICATION OF ELICITING MURPHY’S SIGN

• Inflamed gallbladder presses against your thumb Patient experience pain or tenderness enough to halt inspiration (usually at end of inspiration)

• If repeated without pressing thumb and patient can now complete a full inspiration, the Murphy’s sign is positive for acute cholecystitis.

Sonographic Murphy’s sign • Palpate right subcostal area using an ultrasound

transducer while patient requested to inspire deeply

• US visualizes the gallbladder and confirms origin of arrest in inspiration and pain objectively when organ is being pushed

• superior to ordinary/clinical Murphy’s sign in that it is possible to press gallbladder accurately i.e. 90 % sensitivity and specificity

Efficacy• High specificity( 79 – 96 %) BUT low sensitivity ( 50-

65 %)

• i.e. if present strongly suggests the diagnosis BUT its absence does not exclude the diagnosis

• Less reliable in elderly age

• Alone not used as diagnostic tools to diagnose acute cholecystitis

• Instead only one of components of diagnostic criteria

Efficacy• False Positive

• Patient may feel pain on inspiration on both sides of costal margins leading to false positive sign• If positive sign elicited in right side, left side should also be

evaluated on similar lines

• False Negative

• Incorrect placement of examiner’s fingers

SURFACE MARKING OF FUNDUS of GALLBLADDERGallbladder/Murphy Point

• Tip of 9th costal cartilage

• Junction of Vertical line passing through Midclavicular line and mid-inguinal point with right costal margin

• Junction of Trans-pyloric plane (of Addison) with right costal margin

• Junction of Linea Semilunaris (= Spigelan line) (lateral border of rectus sheath) with right costal margin.

• Point where diagonal line drawn from left ASIS passing through the umbilicus meets right costal margin

WHAT DOES IT INDICATES:Acute cholecystitis or Chronic Cholecystitis?

REFERNECES IN FAVOUR OF ACUTE CHOLECYSTITIS

REFERENCES IN FAVOUR OF CHRONIC CHOLECYSTITIS

Browse’s introduction to the symptoms and signs of surgical disease, 4th edition, Norman L. Browse, pg. 398

A manual on Clinical surgery 10th edition (S. Das) pg. 470, 510

Schwartz’s Principles of Surgery, 10th edition, pg. 1320 SRB’s Clinical Methods in surgery, Sriram Bhat M, Jaypee pg. 479

Bailey & Love’s Short Practice of Surgery, International student’s edition, 26th edition, Page # 1107

SRB’s Manual of Surgery, 3rd Edition, Sriram Bhat M, Jaypee, pg. 580-1

Essential Surgical Practice , International Student Edition , 5th Edition, Alfred Cuschieri Page #712TG13: Updated Tokyo guidelines for acute cholecystitis(J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):1-105)Current Diagnosis and Treatment Surgery, 13th edition, Edited by Gerard M. Doherty ,Lange, Chapter 25The Washington Manual of Surgery, 6th edition, pg. 365Oxford Handbook of Clinical Surgery, 3rd edition, pg. 300

• Acute cholecystitis…………Tenderness and rigidity can be easily elicited on the gallbladder point. gallbladder is hardly palpable…..Overlying rigidity stands in the way of better palpation

(A manual on Clinical surgery. 10th edition. Somen Das. pg. 470)

• Chronic cholecystitis……………..on palpation the most important sign is that of Murphy. In majority of cases gallbladder is not palpable unless mucocele or empyema develops.

(A manual on Clinical surgery. 10th edition. Somen Das.pg. 510)

• Chronic Cholecystitis…..clinical features……positive Murphy’s sign where, in sitting position during deep inspiration, patients winces with pain at summit of respiration while palpating in right hypochondrium.

(SRB’s Clinical Methods in surgery, Sriram Bhat M, Jaypee pg. 479)

(SRB’s Manual of Surgery, 3rd Edition, Sriram Bhat M, Jaypee, pg. 580-1)

• Acute Cholecystitis…………..clinical manifestations………A Murphy’s sign, an inspiratory arrest with deep palpation in the right subcostal area, is characteristic of acute cholecystitis.

• Chronic Cholecystitis (biliary Colic)……..Physical examination may reveal mild right upper quadrant tenderness during episode of pain. If patient is pain free, the physical examination is usually unremarkable…….

(Schwartz’s Principles of Surgery, 10th edition, pg. 1320)

• Gallstones (cholelithiasis)………..Diagnosis………..In the acute phase, the patient may have right upper quadrant tenderness that is exacerbated during inspiration by the examiner’s right subcostal palpation (Murphy’s sign). A positive Murphy’s sign suggests acute inflammation………

(Bailey & Love’s Short Practice of Surgery, International student’s edition, 26th edition, Page # 1107)

• Acute Cholecystitis…….Examination…..Palpation…….Palpate the abdomen just below the tip of the 9th costal cartilage and ask the patient to take a deep breath. When the liver and the attached gallbladder descend and strike the palpating hand, the patient will experience a sharp pain which prevents further inspiration. This is called Murphy’s sign.

• Chronic Cholecystitis…..examination…..Palpation……The patient is tender in the RHC just below the tip of the 9th rib, the point where the edge of the rectus abdominis muscle crosses the costal margin……..

(Browse’s introduction to the symptoms and signs of surgical disease, 4th edition, Norman L. Browse, pg. 398)

• Acute biliary colic and acute cholecystitis…….Acute obstructive (calculous) cholecystitis……symptoms and signs………………In these instances, Murphy’s sign (inspiratory arrest due to pain on inspiration during gentle palpation of the right subcostal region) is usually present.

• Chronic Cholecystitis………. The only reliable sign, which is infrequently found on clinical examination, is tenderness in the right upper quadrant. More often than not, the clinical features of chronic cholecystitis are non-specific and confirmation by imaging tests (usually ultrasonography) is essential for diagnosis in the vast majority of cases.

(Essential Surgical Practice , International Student Edition , 5th Edition, Alfred Cuschieri Page #712)

TG13: Updated Tokyo guidelines for acute cholecystitis(J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):1-105)

• Acute Cholecystitis……….clinical findings……symptoms and signs……..Right upper quadrant tenderness is present, and in about a third of patients the gallbladder is palpable (often in a position lateral to its normal one). Voluntary guarding during examination may prevent detection of an enlarged gallbladder. In others, the gallbladder is not enlarged because scarring of the wall restricts distention. If instructed to breathe deeply during palpation in the right subcostal region, the patient experiences accentuated tenderness and sudden inspiratory arrest (Murphy sign).

• Gallstones & Chronic Cholecystitis (Biliary Colic)……… clinical findings……symptoms and signs ………During an attack, there may be tenderness in the right upper quadrant, and, rarely, the gallbladder is palpable.

(Current Diagnosis and Treatment Surgery, 13th edition, Edited by Gerard M. Doherty ,Lange, Chapter 25)

• Acute calculous Cholecystitis…..Diagnosis……Murphy’s sign (inspiratory arrest during deep palpation of the right upper quadrant) is characteristic of acute cholecystitis and is most informative when the acute inflammation has subsided and direct tenderness is absent.

(The Washington Manual of Surgery, 6th edition, pg. 365)

• Gallbladder stones……..clinical features……acute cholecystitis……Tenderness over gallbladder during inspiration (Murphy’s sign).

(Oxford Handbook of Clinical Surgery, 3rd edition, pg. 300)

CONCLUSION

• According to Indian authors, Murphy’s sign is part of chronic cholecystitis.

• According to rest of international authors (including the latest guidelines regarding acute cholecystitis), Murphy’s sign is part of acute cholecystitis.

Available at surgicalpresenations