# A 47-year-old female patient presents to the emergency department with severe right upper quadrant pain that began 2 hours after eating a large, fatty meal. Which clinical manifestation would provide the strongest evidence for this diagnosis?

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## 문제

A 47-year-old female patient presents to the emergency department with severe right upper quadrant pain that began 2 hours after eating a large, fatty meal. Which clinical manifestation would provide the strongest evidence for this diagnosis?

## 보기

1. Rebound tenderness in the left lower quadrant
2. Clay-colored stools and dark amber urine
3. Positive Murphy's sign with inspiratory arrest **✔ 정답**
4. Cramping pain that moves from periumbilical to right lower quadrant

**정답: 3**

## 해설

Murphy's sign is the most specific clinical assessment finding for acute cholecystitis, involving inspiratory arrest when the examiner palpates the right subcostal area during deep inspiration due to inflamed gallbladder contact with the examining hand. This is consistent with the patient's presentation of severe right upper quadrant pain after a fatty meal. Rebound tenderness in the left lower quadrant (option 1) is more indicative of conditions like diverticulitis or colitis, not cholecystitis. Clay-colored stools and dark amber urine (option 2) suggest biliary obstruction or liver issues but are less specific and may occur later in cholecystitis. Cramping pain that moves from periumbilical to right lower quadrant (option 4) is classic for appendicitis, not cholecystitis.

## 심화 해설

Understanding the Clinical Presentation

The scenario describes a classic presentation for acute cholecystitis: a middle-aged female with severe right upper quadrant (RUQ) pain triggered by a fatty meal. The underlying pathophysiology involves a gallstone obstructing the cystic duct, leading to bile stasis, inflammation, and distension of the gallbladder [1]. The question asks for the clinical sign that provides the strongest evidence for this specific diagnosis.

Analysis of the Correct Answer

The correct answer is 3. Positive Murphy's sign with inspiratory arrest.

A positive Murphy's sign is a highly specific physical exam finding for acute cholecystitis. It is elicited when the examiner palpates deeply in the patient's RUQ, just below the costal margin at the mid-clavicular line, and asks the patient to take a deep breath. As the inflamed, distended gallbladder descends during inspiration and contacts the examiner's hand, the patient experiences a sudden, sharp increase in pain and abruptly ceases inspiration [1]. This finding directly links the physical exam maneuver to the anatomical location of the inflamed gallbladder, making it the strongest evidence among the options provided.

Analysis of Incorrect Answers

1. Rebound tenderness in the left lower quadrant is incorrect because it points to peritoneal irritation in a location anatomically distant from the gallbladder. This finding is more suggestive of left-sided pathologies like diverticulitis and does not support a diagnosis of acute cholecystitis.

2. Clay-colored stools and dark amber urine are signs of post-hepatic biliary obstruction, where bile cannot flow into the duodenum. While gallstones can cause this, these symptoms are more characteristic of a common bile duct obstruction (choledocholithiasis), not an isolated cystic duct obstruction causing cholecystitis. They indicate a complication or a different stage of gallstone disease rather than providing the strongest direct evidence for acute gallbladder inflammation itself [1].

4. Cramping pain that moves from periumbilical to right lower quadrant is the classic pain progression for acute appendicitis, not cholecystitis. The pain of acute cholecystitis is localized to the RUQ and may radiate to the right shoulder or scapula, but it does not typically start periumbilically and migrate to the lower quadrant.

Pathophysiological Connection

Gallstone disease is one of the most prevalent digestive disorders, and a significant number of patients with gallstones will eventually develop symptoms or complications like acute cholecystitis requiring medical intervention [1]. The sequence of events—fatty meal ingestion stimulating cholecystokinin release, gallbladder contraction against an obstructed cystic duct, and subsequent inflammation—explains the localized RUQ pain and the specific, reproducible finding of a positive Murphy's sign. This sign is a direct clinical manifestation of the distended, inflamed gallbladder's inability to descend without pain, making it the most compelling piece of evidence for the diagnosis in this acute setting.References (research sources)

- [1]Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations.Research articlePortincasa P, Di Ciaula A, Bonfrate L, Stella A, Garruti G, Lamont JT. (2023) · DOI: 10.1007/s11739-023-03355-z

## 임상 시나리오

Assessing for Acute CholecystitisPerforming and Interpreting Murphy's Sign
To elicit Murphy's sign, place your hand at the patient's right upper quadrant along the mid-clavicular line and ask them to take a deep breath. A positive sign is an abrupt cessation of inspiration due to sharp pain as the inflamed gallbladder contacts your hand.

A positive Murphy's sign is highly specific for acute cholecystitis, especially in a patient presenting with postprandial RUQ pain. It should be differentiated from sonographic Murphy's sign performed during an ultrasound.

CautionDo not confuse with rebound tenderness, which indicates peritoneal inflammation. Murphy's sign is localized to the gallbladder fossa and is not a test for peritonitis. A negative sign does not rule out cholecystitis, particularly in elderly or diabetic patients.

## 핵심 개념

- **Murphy's Sign** — A physical exam finding for acute cholecystitis where deep palpation in the right upper quadrant during inspiration causes abrupt pain and inspiratory arrest.
- **Acute Cholecystitis** — Inflammation of the gallbladder, most commonly caused by a gallstone obstructing the cystic duct, leading to bile stasis and distension.
- **Inspiratory Arrest** — The sudden cessation of inspiration due to sharp pain when an inflamed gallbladder contacts the examiner's hand during a Murphy's sign test.
- **Rebound Tenderness** — Pain upon sudden release of deep palpation pressure, indicating peritoneal inflammation or peritonitis.
- **Common Bile Duct Obstruction** — Blockage of the duct carrying bile from the liver and gallbladder to the duodenum, often causing jaundice, dark urine, and clay-colored stools.

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