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

This presentation gives answer to the question regarding MURPHY'S SIGN (of cholecystitis/gallbladder) that whether it is sign of ACUTE CHOLECYSTITIS or CHRONIC CHOLECYSTITIS?

1. JIBRAN MOHSIN RESIDENT, SURGICAL UNIT I SIMS / SERVICES HOSPITAL, LAHORE MURPHY’S SIGN of cholecystitis/gallbladder: sign of acute or chronic cholecystitis?

2. John Benjamin Murphy (1857-1916) American physician  and abdominal   surgeon advocated early surgical intervention in appendicitis (appendectomy) and several eponyms

3. 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."

4. John Benjamin Murphy Performed 1 st biliary tract endoscopy (1912) 1 st to do femoral artery anastomosis after gunshot injury (1896) 1 st   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

5. John Benjamin Murphy EPONYMS CLINICAL   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 3 rd MCP joint in line with adjacent MCP joints in fist Lunate Dislocation Murphy’s triad Pain  vomiting  Fever Acute appendicitis

6. John Benjamin Murphy EPONYMS 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

7. 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.

8. 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)

9. 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

10. 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

11. 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 9 th 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

12. 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).

13. 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

14. 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.

15. 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

16. 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

17. 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

18. SURFACE MARKING OF FUNDUS of GALLBLADDER Gallbladder/Murphy Point Tip of 9 th 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 d iagonal line drawn from left ASIS passing through the umbilicus meets right costal margin

19. 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, 4 th edition , Norman L. Browse, pg. 398 A manual on Clinical surgery 10 th edition (S. Das) pg. 470, 510 Schwartz’s Principles of Surgery, 10 th 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, 26 th edition, Page # 1107 SRB’s Manual of Surgery, 3 rd Edition, Sriram Bhat M, Jaypee , pg. 580-1 Essential Surgical Practice , International Student Edition , 5 th Edition, Alfred Cuschieri Page # 712 TG13: Updated Tokyo guidelines for acute cholecysti tis (J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):1-105 ) Current Diagnosis and Treatment Surgery, 13 th edition, Edited by Gerard M. Doherty ,Lange, Chapter 25 The Washington Manual of Surgery, 6 th edition, pg. 365 Oxford Handbook of Clinical Surgery, 3 rd edition, pg. 300

20. 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. 10 th 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. 10 th edition. Somen Das.pg . 510)

21. 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, 3 rd Edition, Sriram Bhat M, Jaypee , pg. 580-1)

22. 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, 10 th edition, pg. 1320)

23. Gallstones ( cholelithiasis )………..Diagnosis……….. I n 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, 26 th edition, Page # 1107)

24. Acute Cholecystitis…….Examination…..Palpation…….Palpate the abdomen just below the tip of the 9 th 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……Th e patient is tender in the RHC just below the tip of the 9 th 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, 4 th edition, Norman L. Browse, pg. 398)

25. 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 , 5 th Edition, Alfred Cuschieri Page # 712)

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

27. 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, 13 th edition, Edited by Gerard M. Doherty ,Lange, Chapter 25)

28. 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, 6 th edition, pg. 365)

29. Gallbladder stones……..clinical features……acute cholecystitis……Tenderness over gallbladder during inspiration (Murphy’s sign). ( Oxford Handbook of Clinical Surgery, 3 rd edition, pg. 300)

30. 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.

31. Available at surgicalpresenations