A 58-year-old woman presents to the emergency department with severe right upper quadrant pain of 8 hours' duration, fever (38.5°C), and nausea. On clinical examination, she has a positive Murphy sign. Abdominal ultrasound is performed. The structure marked **D** in the diagram (sonographic Murphy sign) is demonstrated as focal tenderness elicited by probe pressure over the visualized gallbladder during inspiration. Which of the following best describes the clinical significance of this finding in acute cholecystitis?

Explanation

## Why Option 1 is correct The sonographic Murphy sign (focal tenderness over the visualized gallbladder during probe pressure and inspiration) is one of the five cardinal ultrasound findings in acute cholecystitis, alongside gallbladder wall thickening >3 mm, pericholecystic fluid, gallstones, and gallbladder distension. According to Bailey & Love 28e and Schwartz Surgery 11e, the sonographic Murphy sign has high sensitivity and specificity for acute cholecystitis. Its diagnostic value is maximized when interpreted in the clinical context of persistent severe RUQ pain (>6 hours), fever, leukocytosis, and other ultrasound features of gallbladder inflammation. The sign reflects the inflammatory response of the gallbladder wall and cystic duct obstruction by a stone (90–95% of cases), and its presence strengthens the diagnosis when combined with these other findings. ## Why each distractor is wrong - **Option 2**: While the sonographic Murphy sign is highly specific, it is NOT pathognomonic (uniquely diagnostic) for acute cholecystitis. A positive sign must always be interpreted alongside clinical presentation and other imaging findings. Diagnosis requires integration of clinical, laboratory, and imaging data, not the sign alone. - **Option 3**: The sonographic Murphy sign indicates acute cholecystitis due to cystic duct obstruction, not choledocholithiasis. Choledocholithiasis is suspected when bilirubin is markedly elevated (>4 mg/dL), the common bile duct is dilated on ultrasound, or jaundice is present—none of which are implied by the Murphy sign alone. ERCP is indicated for suspected CBD stones, not for uncomplicated acute cholecystitis. - **Option 4**: The sonographic Murphy sign is a specific finding in acute cholecystitis caused by inflammation and cystic duct obstruction. In uncomplicated biliary colic (transient cystic duct obstruction without inflammation), the Murphy sign is typically absent. This distinction is clinically important: biliary colic resolves spontaneously within hours, whereas acute cholecystitis requires urgent intervention (antibiotics, fluids, early laparoscopic cholecystectomy within 72 hours per Tokyo Guidelines 2018). **High-Yield:** Sonographic Murphy sign = focal GB tenderness on probe pressure during inspiration; high sensitivity + specificity for acute cholecystitis when combined with wall thickening, pericholecystic fluid, and clinical features (fever, RUQ pain >6 hr, leukocytosis). [cite: Bailey & Love 28e Ch 70; Schwartz Surgery 11e]