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Internal hernias are rare, and a delayed diagnosis can lead to dangerous complications. A 75-year-old male with no previous surgical history presented with right upper abdominal pain and vomiting. On examination, he had guarding in the right hypochondrium with a positive Murphy's sign. However, ultrasonography of the gall bladder was normal with dilated bowel loops. Contrast-enhanced CT (CECT) revealed a falciform hernia with evidence of obstruction. Segmental resection of the gangrenous ileum was done with a double-barrel stoma. Later on, stoma reversal was also done with no complications.

A positive Murphy’s sign in a patient with right upper quadrant abdominal pain is the arrest of inspiration during deep palpation of the quadrant. It is usually suggestive of acute cholecystitis. We report an unusual case of a positive Murphy’s sign not due to acute cholecystitis, but rather from a pericardial hematoma from a right atrial tear causing right heart failure. The patient required an atrial tear repair to prevent a cardiac tamponade.

Objective We sought to develop a practical Bedside Score for the diagnosis of cholecystitis and test its accuracy against the Tokyo Guidelines (TG13). Methods We conducted a retrospective study of 438 patients undergoing urban, academic Emergency Department (ED) evaluation of RUQ pain. Symptoms, physical signs, ultrasound signs, and labs were scoring system candidates. A random split-sample approach was used to develop and validate a new clinical score. Multivariable regression analysis using development data was conducted to identify predictors of cholecystitis. Cutoff values were chosen to ensure positive/negative predictive values (PPV, NPV) of at least 0.95. The score was externally validated in 80 patients at a different hospital undergoing RUQ pain evaluation. Results 230 patients (53%) had cholecystitis. Five variables predicted cholecystitis and were included in the scores: gallstones, gallbladder thickening, clinical or ultrasonographic Murphy's sign, RUQ tenderness, and post-prandial symptoms. A clinical prediction score was developed. When dichotomized at 4, overall accuracy for acute cholecystitis was 90% for the development cohort, 82% and 86% for the internal and external validation cohorts; TG13 accuracy was 62%–79%. Conclusions A clinical prediction score for cholecystitis demonstrates accuracy equivalent to TG13. Use of this score may streamline work-up by decreasing the need for comprehensive ultrasound evaluation and CRP measurement and may shorten ED length of stay.

Background The Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were published in 2007 as the world's first guidelines for acute cholangitis and cholecystitis. The diagnostic criteria and severity assessment of acute cholecystitis have since been widely used all over the world. A validation study of TG07 has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. In addition, considerable new evidence referring to acute cholecystitis as well as evaluations of TG07 have been published. Consequently, we organized the Tokyo Guidelines Revision Committee to evaluate TG07, recognize new evidence, and conduct a multi-center analysis to revise the guidelines (TG13).Methods and materials We retrospectively analyzed 451 patients with acute cholecystitis from multiple tertiary care centers in Japan. All 451 patients were first evaluated using the criteria in TG07. The "gold standard" for acute cholecystitis in this study was a diagnosis by pathology. The validity of TG07 diagnostic criteria was investigated by comparing clinical with pathological diagnosis.Results Of 451 patients evaluated, a total of 227 patients were given a diagnosis of acute cholecystitis by pathological examination (prevalence 50.3 %). TG07 criteria provided a definite diagnosis of acute cholecystitis in 224 patients. The sensitivity of TG07 diagnostic criteria for acute cholecystitis was 92.1 %, and the specificity was 93.3 %. Based on the preliminary results, new diagnostic criteria for acute cholecystitis were proposed. Using the new criteria, the sensitivity of definite diagnosis was 91.2 %, and the specificity was 96.9 %. The accuracy rate was improved from 92.7 to 94.0 %. In regard to severity grading among 227 patients, 111 patients were classified as Mild (Grade I), 104 as Moderate (Grade II), and 12 as Severe (Grade III).Conclusion The proposed new diagnostic criteria achieved better performance than the diagnostic criteria in TG07. Therefore, the proposed criteria have been adopted as new diagnostic criteria for acute cholecystitis and are referred to as the 2013 Tokyo Guidelines (TG13). Regarding severity assessment, no new evidence was found to suggest that the criteria in TG07 needed major adjustment. As a result, TG07 severity assessment criteria have been adopted in TG13 with minor changes.

Administering analgesia to patients with abdominal pain before diagnostic imaging is now accepted as standard practice. However, analgesia before diagnostic right upper quadrant ultrasound continues to be controversial for fear of masking the sonographic Murphy's sign (SMS). This study sought to evaluate the impact of analgesia on the accuracy of the SMS in predicting cholecystitis. We hypothesized that the impact of analgesia on radiologist-performed ultrasound and emergency physician (EP)-performed ultrasound would be equivalent.Thirty patients presenting to the emergency department with abdominal pain were randomized to receive placebo or meperidine for the first two doses of medication. The patients underwent EP performed right upper quadrant ultrasound before and after the administration of medication, in addition to receiving a radiology department ultrasound postmedication. The presence of SMS was then compared with final hospital or pathological diagnosis.Eleven of 30 patients (37%) had a final diagnosis of cholecystitis and only one patient had a change in their SMS postmedication. The EP assessment for postmedication SMS had a sensitivity of 0.82 [confidence interval (CI): 0.48-0.97] and specificity of 0.95 (CI: 0.71-0.99) for cholecystitis. The radiology assessment for postmedication SMS had a sensitivity of 0.17 (CI: 0.01-0.63) and specificity of 1 (CI: 0.74-1) for cholecystitis.This pilot study shows that analgesia does not significantly change the assessment of SMS when performed by an EP sonographer. It also suggests that EP-performed ultrasound may be more accurate in assessing this predictive sign of cholecystitis.

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.

The patient was treated with a diagnostic laparoscopy and open appendicectomy by Kocher’s incision. The second patient was a 30-year-old who also presented with a positive Murphy’s sign and some tenderness in the anterior lumbar region. A laparoscopy confirmed subhepatic appendicitis (Figure 2). The appendix was removed laparoscopically. These cases confirm that Murphy’s sign is not pathognomonic of

Three years have passed since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis, and we believe that the time has come to assess their validity. In this study, we validated the diagnostic accuracy of these criteria in 74 patients with an initial diagnosis of acute cholangitis and 81 patients with an initial diagnosis of acute cholecystitis. We also statistically compared the accuracy of the diagnosis made based on the Tokyo Guidelines with that based on the presence of Charcot’s triad for acute cholangitis and Murphy’s sign for acute cholecystitis with use of the sign test to assess differences. The results revealed that the diagnostic sensitivity and specificity of the Tokyo Guidelines for suspected or definitive acute cholangitis were 72.1 and 38.5%, respectively, and the corresponding values for definitive cholangitis alone were 63.9 and 69.2%, respectively. For definitive acute cholecystitis, the diagnostic sensitivity and specificity of the Tokyo Guidelines were 84.9 and 50.0%, respectively. The accuracy of diagnosis based on the Tokyo Guidelines was significantly higher than that based on the presence of Charcot’s triad (acute cholangitis, p

Acute cholecystitis associated with gallbladder carcinoma is very rare in young patients (younger than 30 years of age). Moreover, a definitive preoperative diagnosis is difficult. A 26-year-old man was referred to our hospital with a 5-day history of right upper quadrant pain. Computed tomography and ultrasonography demonstrated an enlarged gallbladder with a diffuse thick wall and a 2-cm gallstone obstructing the cystic duct. Magnetic resonance cholangiopancreatography showed no evidence of an anomalous pancreaticobiliary junction. The patient showed an elevation in the white blood cell count, serum C-reactive protein, and alkaline phosphate; however, total bilirubin, alanine aminotransferase, and tumor markers including carcinoembryonic antigen and carbohydrate antigen 19-9 were all within the normal ranges. The preoperative diagnosis of gallstone-induced acute cholecystitis was made and an open cholecystectomy was thus performed 2 days after admission. The macroscopic findings showed a necrotic enlarged gallbladder with a thick wall and a gallstone, but no intraluminal nodular lesion. Histologic examinations revealed well-differentiated focal adenocarcinoma in the gallbladder mucosa, but no venous, lymphatic, or perineural invasion. The postoperative course has been uneventful with no recurrence 18 months postoperatively.

Abdominal complications following cardiac surgery remain unusual, but are associated with high mortality. The most common abdominal surgical complications are mesenteric ischaemia, diverticulitis, pancreatitis, gastrointestinal bleeding and cholecystitis. We describe a case of a 73-year old woman with acute abdominal pain mimicking cholecystitis on day 10 after aortic valve replacement. An abdominal examination showed tenderness of the right upper quadrant with Murphy's sign. Complete blood count, blood chemistries and urinalysis were normal as were the abdominal and chest X-rays and abdominal ultrasonography. The abdominal computed-tomography (CT) scan enabled us to rule out cholecystitis, as it demonstrated the typical appearance of epiploic appendagitis on the right colon, 1 cm below the gallbladder. Epiploic appendagitis results from twisting, kinking or venous thrombosis of an epiploic appendage. Depending on its localization, it mimics many diagnoses requiring surgery: colitis, diverticulitis, appendicitis and cholecystitis. An abdominal CT scan is the diagnostic imaging tool of choice. All physicians involved in post-cardiac surgery care should be aware of this self-limiting disease that usually resolves with non-steroidal anti-inflammatory drugs and watchful waiting, and to avoid unnecessary surgery because the spontaneous evolution of epiploic appendagitis is usually benign.

Murphy's sign is a sensitive test used to ascertain the cause of abdominal pain. Susan Thomas outlines the procedure of the test and what elicits a positive result

ContextAlthough few patients with acute abdominal pain will prove to have cholecystitis, ruling in or ruling out acute cholecystitis consumes substantial diagnostic resources.ObjectiveTo determine if aspects of the history and physical examination or basic laboratory testing clearly identify patients who require diagnostic imaging tests to rule in or rule out the diagnosis of acute cholecystitis.Data SourcesElectronic search of the Science Citation Index, Cochrane Library, and English-language articles from January 1966 through November 2000 indexed in MEDLINE. We also hand-searched Index Medicus for 1950-1965, and scanned references in identified articles and bibliographies of prominent textbooks of physical examination, surgery, and gastroenterology. To identify relevant articles appearing since the comprehensive search, we repeated the MEDLINE search in July 2002.Study SelectionIncluded studies evaluated the role of the history, physical examination, and/or laboratory tests in adults with abdominal pain or suspected acute cholecystitis. Studies had to report data from a control group found not to have acute cholecystitis. Acceptable definitions of cholecystitis included surgery, pathologic examination, hepatic iminodiacetic acid scan or right upper quadrant ultrasound, or clinical course consistent with acute cholecystitis and no evidence for an alternate diagnosis. Studies of acalculous cholecystitis were included. Seventeen of 195 identified studies met the inclusion criteria.Data ExtractionTwo authors independently abstracted data from the 17 included studies. Disagreements were resolved by discussion and consensus with a third author.Data SynthesisNo clinical or laboratory finding had a sufficiently high positive likelihood ratio (LR) or low negative LR to rule in or rule out the diagnosis of acute cholecystitis. Possible exceptions were the Murphy sign (positive LR, 2.8; 95% CI, 0.8-8.6) and right upper quadrant tenderness (negative LR, 0.4; 95% CI, 0.2-1.1), though the 95% CIs for both included 1.0. Available data on diagnostic confirmation rates at laparotomy and test characteristics of relevant radiological investigations suggest that the diagnostic impression of acute cholecystitis has a positive LR of 25 to 30. Unfortunately, the available literature does not identify the specific combinations of clinical and laboratory findings that presumably account for this diagnostic success.ConclusionsNo single clinical finding or laboratory test carries sufficient weight to establish or exclude cholecystitis without further testing (eg, right upper quadrant ultrasound). Combinations of certain symptoms, signs, and laboratory results likely have more useful LRs, and presumably inform the diagnostic impressions of experienced clinicians. Pending further research characterizing the pretest probabilities associated with different clinical presentations, the evaluation of patients with abdominal pain suggestive of cholecystitis will continue to rely heavily on the clinical gestalt and diagnostic imaging.

The history of the acute abdomen describes a shift from emphasis on prognosis to treatment through correlation of clinical and pathological findings. John B. Murphy was an acclaimed leader of American surgery whose name is associated with several diagnostic maneuvers used in the evaluation of the acute abdomen. These include deep-grip palpation used in examination for suspected biliary disease.