The sonographic diagnosis of acute gangrenous cholecystitis: importance of the Murphy sign.

The sonographic Murphy sign is defined as the presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder. The reported prevalence of this sign is more than 95% in patients with acute cholecystitis. In this series of 18 patients with pathologically proved gangrenous cholecystitis, the sonographic Murphy sign was positive in only six (33%). Clinical examination showed a positive Murphy sign in eight patients (44%), diffuse abdominal pain in nine patients (50%), and no pain in one patient (6%). Other sonographic findings included pericholecystic fluid (10), thickening of the gallbladder wall (10), and a dilated gallbladder (five). Our experience suggests that the absence of the Murphy sign increases the possibility of gangrenous cholecystitis in patients with abdominal pain and sonographic findings of cholecystitis.