por He cystic point, or Murphy’s point, is an abdominal landmark that indicates the topographic location of the gallbladder. The point is located below the right costal margin where the midclavicular line meets the costal margin.
This is the site where the gallbladder is normally located inside the abdomen. Locating this point is important when the doctor suspects inflammation of the gallbladder, a condition known as acute cholecystitis.
The gallbladder is an intra-abdominal organ found below the liver. It is part of the digestive system and serves as a reservoir for bile. In turn, bile is a liquid produced by the liver that has an important role in the digestion and absorption of fats. It contains salts, proteins, cholesterol and water.
The most common disease of the gallbladder is gallstones, which is nothing more than the formation of stones or lithiasis within that organ. The presence of these stones causes pain and sometimes obstructs the outflow of bile.
In any case, inflammation of the gallbladder walls can occur, causing acute cholecystitis. When the cystic point is painful there is a high probability that the patient is suffering from cholecystitis.
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Cystic point and Murphy’s sign
The cystic point is the reflection of the location of the gallbladder on the abdominal wall of a person. It is used as a reference to know where the gallbladder is located and thus be able to examine it.
The point is in the right hypochondrium of the abdomen. It is the intersection between the midclavicular line and the costal margin. The midclavicular line is an imaginary line that is drawn from the middle of the clavicle and extends downward.
This image is the projection of the location of the gallbladder on the abdominal wall.
To demonstrate Murphy’s sign, the clinician should locate the cystic point and apply gentle pressure while asking the patient to take a strong, sustained breath. This breathing movement causes the liver to descend and the gallbladder, which is located below the liver, to touch the doctor’s hand.
When the inflamed gallbladder finds the examiner’s hands, the patient feels severe pain that causes him to stop breathing. When this happens, Murphy’s sign is considered positive. It is a specific sign for acute cholecystitis.
The sign was described by the eminent surgeon John Benjamin Murphy (1857-1916) who made great contributions to the field of abdominal surgery and whom Dr. William Mayo described as the surgical genius of that generation.
When Murphy’s sign is positive, there is a 79% certainty percentage for the diagnosis of acute cholecystitis. Confirmation of the disease is provided by abdominal ultrasound, which is the recommended examination for evaluation of the gallbladder.
Clinical significance of the cystic point
The cystic point is a topographic landmark that tells the doctor where the gallbladder is located. The importance of knowing its location is that the symptoms and signs of gallbladder disease are very specific. Having this high specificity, it is important to demonstrate them to advance in the diagnosis of biliary disease.
The doctor must know the anatomy of the abdominal cavity and the topographic location of the organs to be able to carry out the necessary maneuvers that bring him closer to the diagnosis of biliary pathology.
Although acute cholecystitis is the most common disease of the gallbladder, other types of conditions can also be found, including malignant gallbladder tumors.
When palpating a firm and large mass that is not painful at the cystic point, the presence of a malignant tumor should be suspected and the pertinent examinations carried out as soon as possible in order to make a timely diagnosis and treatment.
Gallbladder: Anatomy
The gallbladder is an organ of the digestive system that belongs to the biliary system. The biliary system is a complex structure of ducts that originate in the liver and are responsible for forming bile.
There is an intra-hepatic and an extra-hepatic biliary system. The gallbladder is part of the extra-hepatic system.
It is located below the liver and is attached to it by fibrous tissue and fat.
The function of the gallbladder is to store and release bile, which is the yellowish-green liquid produced by the liver for the digestion of fats.
The gallbladder is activated by a reflex mechanism when emptying of the stomach into the duodenum begins. Activation consists of its contraction for the expulsion of bile, which binds to the fats in food and helps in its absorption and digestion.
When the bile is highly loaded with cholesterol salts or when the movements of the gallbladder are very slow, stones or gallstones can form. These formations remain inside the cavity of the gallbladder and are an obstacle at the time of contraction.
When the gallbladder contracts and there are stones inside, the patient presents a sharp pain of very strong intensity called biliary colic.
The presence of stones in the gallbladder, as well as the slow contraction response of the gallbladder are two of the causes that generate, in the medium term, inflammation of the gallbladder or acute cholecystitis.
Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder. The most common cause of cholecystitis is the presence of stones inside the gallbladder and the obstruction of its outlet duct, known as the cystic duct.
Cholecystitis pain is one of the main reasons for acute abdominal pain consultation in young and middle-aged women. This disease occurs more frequently in women than in men.
Cholecystitis is characterized by cramping pain located in the right hypochondrium, below the costal margin. A colicky pain is one that appears suddenly, reaching a peak in which the pain becomes very intense, calming down later until it improves completely. It is not a continuous pain.
This pain occurs with the ingestion of fatty foods or foods high in carbohydrates since they are the ones that stimulate the activity of the gallbladder.
When this disease is diagnosed, it must be treated immediately through the administration of antibiotics and the performance of a surgical procedure called cholecystectomy. Cholecystectomy is an abdominal operation that consists of removing the diseased gallbladder.
It is important to diagnose and treat the patient with cholecystitis as soon as possible since when the disease progresses it can have serious complications that endanger the life of the person who suffers from it.
Diagnosis
The diagnostic approach towards acute cholecystitis begins with the questioning and analysis of the symptoms that the patient has presented in recent months.
These are generally women who complain of digestive disorders such as gas, bloating, and nausea after eating large or high-fat meals.
Biliary colic is a specific pain of this disease that is triggered by the ingestion of food. The pain that starts mild, reaches a point of very strong intensity within a few minutes. This can improve with the administration of antispasmodic drugs. These drugs are those that relax the muscles of the gallbladder.
If no medication is administered, the pain subsides after a few minutes and may occur several times during the day.
The diagnosis of acute cholecystitis is established through physical examination and abdominal ultrasound, which is the most specific examination for the diagnosis of gallstones and acute cholecystitis.
Within the physical examination, Murphy’s cystic point must be located and the patient’s forced inspiration maneuver must be performed to demonstrate Murphy’s sign.
References
Musana, K; Yale, S.H. (2005). John Benjamin Murphy (1857-1916). Clinical medicine & research. Taken from: ncbi.nlm.nih.gov
Jones, MW; Deppen, JG. (2019). Physiology, Gallbladder. Treasure Island (FL). Taken from: ncbi.nlm.nih.gov
Njeze GE (2013). Gallstones. Nigerian journal of surgery: official publication of the Nigerian Surgical Research Society. Taken from: ncbi.nlm.nih.gov
Sanders, G.; Kingsnorth, AN (2007). Gallstones. Taken from: ncbi.nlm.nih.gov
Tanaja J, Meer JM. cholelithiasis. Treasure Island (FL). Taken from: ncbi.nlm.nih.gov