Murphy Sign: An Evidence-Based Guide for Patients

Murphy sign is a physical exam finding in which pain occurs when a doctor presses under the right rib cage during a deep breath. It can point to gallbladder inflammation, especially acute cholecystitis, but it must be interpreted together with symptoms, blood tests, and imaging.

What is Murphy sign?

Murphy sign is a clinical finding checked during an abdominal examination. It is considered positive when a person feels pain and suddenly stops inhaling as a clinician presses gently below the right rib cage while the person takes a deep breath. This response can happen when the inflamed gallbladder moves downward and touches the examiner’s hand.

In practical terms, Murphy sign helps doctors assess whether right upper abdominal pain may be coming from the gallbladder. It is most closely associated with acute cholecystitis, which is inflammation of the gallbladder, often related to gallstones. However, it is not specific enough to confirm a diagnosis by itself.

Like many physical exam signs, Murphy sign is one piece of a larger clinical picture. Doctors also consider when the pain started, whether there is fever, nausea, vomiting, jaundice, or pain after eating, as well as a person’s age, medical history, and examination findings.

How doctors test for Murphy sign

To check for Murphy sign, the clinician usually asks the patient to lie on their back and relax the abdominal muscles. The examiner places a hand just below the right costal margin, roughly where the gallbladder sits, and asks the patient to breathe in deeply.

If inhalation causes a sharp increase in pain at that spot and the breath is cut short, the sign may be considered positive. The finding is often compared with the left side or with other areas of the abdomen to understand whether the tenderness is localized or more general.

This exam is helpful because it is quick, noninvasive, and available in almost any care setting. Even so, the result can be less reliable in some people, including older adults, people with diabetes-related nerve changes, or those who have difficulty describing pain. For this reason, a positive or negative Murphy sign always needs clinical context.

What a positive Murphy sign may mean

The condition most classically linked to a positive Murphy sign is gallstones causing acute cholecystitis. In this setting, a stone may block the cystic duct, leading to swelling, irritation, and sometimes infection of the gallbladder. Pain is often felt in the upper right abdomen and may spread to the right shoulder or back.

People may also notice nausea, vomiting, fever, bloating, or pain that becomes worse after a fatty meal. Some have tenderness that is strong enough to limit deep breathing during the exam. If the bile ducts are affected as well, yellowing of the skin or eyes can occur and requires prompt assessment.

However, Murphy sign does not always mean acute cholecystitis. Right upper abdominal pain can also come from other digestive or liver-related conditions, including bile duct problems, hepatitis, peptic ulcer disease, or pancreatitis. In some cases, even right lower lung infections or inflammation near the diaphragm can produce similar discomfort.

• Commonly associated with: acute cholecystitis
• Often related to: gallstones blocking bile flow
• May overlap with: liver, stomach, pancreas, lung, or bile duct conditions

Symptoms that often appear with Murphy sign

Murphy sign is not something most people notice on their own; it is usually identified during an exam. What brings people to care is the symptom pattern around it. The most common complaint is pain in the upper right side of the abdomen, especially pain that lasts more than a few hours or becomes intense.

Other symptoms can include fever, chills, nausea, vomiting, loss of appetite, abdominal bloating, and pain after meals. Some people describe a steady ache rather than cramping. Others feel pain that travels to the right shoulder blade or mid-back.

When these symptoms occur together, clinicians may evaluate for cholecystitis or related gallbladder disorders. If jaundice, dark urine, pale stools, confusion, fainting, or severe dehydration are present, the situation may be more urgent because these can suggest a blocked bile duct or infection.

How the cause is diagnosed

Diagnosis begins with a careful history and physical examination. A doctor will ask about the location and timing of pain, recent meals, fever, vomiting, prior gallstones, pregnancy, medications, and previous abdominal surgery. Murphy sign may raise suspicion, but the diagnosis is usually confirmed through additional testing.

Blood tests often look for signs of inflammation, infection, liver irritation, or pancreatic involvement. Imaging is especially important. Ultrasound is commonly the first test because it can show gallstones, gallbladder wall thickening, surrounding fluid, and tenderness when the probe is pressed over the gallbladder.

Depending on the symptoms, doctors may also consider CT scanning or specialized biliary imaging. In some cases, an imaging study shows what is called a sonographic Murphy sign, meaning the person feels maximal tenderness when the ultrasound probe presses directly over the gallbladder. This can add useful information, but it is still interpreted alongside the full clinical picture. If diagnosis remains uncertain, a physician may recommend MRI or CT scan as part of the evaluation.

Treatment and what happens next

Treatment depends on the underlying cause rather than the Murphy sign itself. When acute cholecystitis is suspected, early medical assessment is important. Initial care may include resting the digestive system, intravenous fluids, pain control, medicines for nausea, and antibiotics if infection is thought to be present.

If gallstones are causing repeated attacks or inflammation, the definitive treatment is often gallbladder surgery. This procedure, called cholecystectomy, is commonly performed using minimally invasive techniques, though the exact plan depends on the patient’s health and the severity of inflammation.

Not everyone with right upper abdominal pain will need surgery. Sometimes the evaluation shows a different problem entirely, such as a liver condition, gastritis, ulcer disease, or pancreatitis, and treatment is directed accordingly. The safest next step is to let a qualified doctor determine the cause rather than assuming that a positive Murphy sign always means the same condition.

When to seek medical care

Medical care should be sought promptly for upper right abdominal pain that is severe, persistent, or accompanied by fever, repeated vomiting, or jaundice. These features can signal gallbladder inflammation, bile duct blockage, or infection, which may need urgent treatment.

Emergency assessment is especially important if the person cannot keep fluids down, feels faint, has trouble breathing because of the pain, develops confusion, or has worsening pain that spreads across the abdomen. People with weakened immune systems, older adults, and pregnant individuals should not delay evaluation when symptoms are significant.

For milder symptoms that come and go, it is still wise to arrange a medical appointment, especially if symptoms recur after meals or there is a past history of gallstones. Near the end of the care pathway, patients who need specialist evaluation may be seen in centers where multidisciplinary teams coordinate imaging, surgery, and digestive care. Acibadem International’s multidisciplinary specialists and JCI-accredited hospitals diagnose and treat gallbladder conditions for international patients.

Frequently asked questions

Is Murphy sign the same as a gallbladder diagnosis?

No. Murphy sign is a physical exam finding that can suggest gallbladder inflammation, but it does not confirm a diagnosis by itself. Doctors usually combine it with symptoms, blood tests, and imaging such as ultrasound.

Can Murphy sign be negative even if a person has gallbladder disease?

Yes. A person can still have gallbladder disease even if Murphy sign is absent, especially if symptoms are less typical or the person has reduced pain sensitivity. That is why doctors do not rely on this sign alone.

What does a positive Murphy sign feel like?

During the exam, the person usually feels pain in the upper right abdomen when taking a deep breath while pressure is applied under the rib cage. The pain may be strong enough to make them stop inhaling suddenly.

Does Murphy sign always mean gallstones?

No. Gallstones are a common reason for a positive Murphy sign, but other conditions can also cause similar right upper abdominal pain. Liver, bile duct, stomach, pancreas, or even some lung problems may need to be considered.

What tests are usually done after Murphy sign is found?

Doctors often order blood tests and an abdominal ultrasound. Depending on the situation, additional imaging such as CT or MRI may be used to clarify the diagnosis or look for complications.

When should someone go to the emergency department for this type of pain?

Emergency care is appropriate if the pain is severe, lasts for hours, or comes with fever, repeated vomiting, jaundice, fainting, or confusion. These symptoms can suggest infection, bile duct blockage, or another urgent abdominal problem.

References

• National Institute of Diabetes and Digestive and Kidney Diseases
• American College of Gastroenterology
• American College of Radiology
• Merck Manual Professional Edition
• Mayo Clinic

This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor about your individual situation.