Indirect Fist Percussion of the Liver Is a More Sensitive Technique for Detecting Hepatobiliary Infections than Murphy’s Sign

Abstract

Background. Murphy's sign and Charcot's triad are established clinical findings of acute cholecystitis and cholangitis, respectively, but both show low sensitivity and limited clinical application. We evaluated if indirect fist percussion of the liver improves the efficiency of diagnosing cholecystitis and cholangitis when used as a diagnostic adjunct. Methods. The presence/absence of right upper quadrant (RUQ) tenderness, Murphy's sign, and pain induced by indirect fist percussion of the liver was assessed, and the results were compared with the definite diagnosis based on ultrasound and additional examinations in patients aged over 18 who visited our outpatient clinic with suspected hepatobiliary diseases. Results. Four hundred and eight patients were investigated, and 40 had hepatobiliary infection (acute cholecystitis: 10, acute cholangitis: 28, liver abscess: 1, and hepatic cyst infection: 1). The sensitivity of indirect fist percussion of the liver for diagnosing hepatobiliary infection was 60%, being significantly higher than that of RUQ tenderness (33%) and Murphy's sign (30%), and its specificity was 85%. There was no significant improvement in sensitivity or diagnostic accuracy when Murphy's sign was combined with indirect fist percussion of the liver. Conclusion. Indirect fist percussion-induced liver pain is a useful clinical finding to diagnose hepatobiliary infection, with high-level sensitivity.

Focal necrosis of the falciform ligament as a rare cause of abdominal pain: A case report

“…The physical findings in these patients further increase the likelihood of misdiagnosis; they usually present with signs and symptoms of typical gallbladder colic, including right hypochondriac and epigastric pain. Some patients, like our patient in this report, show a positive Murphy’s sign, a very sensitive sign of acute cholecystitis (sensitivity around 80%, and specificity more than 90%), 7 making it crucial to keep in mind falciform ligament necrosis even in the presence of such a specific sign for acute cholecystitis. 5 , 8 Most patients present with nonspecific blood test results, which usually include mild elevations in inflammatory markers and WBCs.…”

Acute Cholecystitis in an Elderly Patient With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Case Report

“…In this case, the surgeon was initially reluctant to perform invasive interventions on a 99-year-old patient. However, the development of clinical features consistent with cholecystitis (i.e., right upper quadrant tenderness on indirect fist liver percussion and a positive Murphy’s sign) [ 15 ] strengthened the decision to push through with invasive interventions, which later revealed ANCA-associated vasculitis. This highlights the importance of going against age-related stereotypes that limit the use of invasive procedures in elderly patients [ 16 ].…”