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.