Classification of symptoms of acute cholecystitis
Acute cholecystitis is an acute inflammation of the gallbladder, the propaedeutic examination of which reveals a characteristic set of pain symptoms. For ease of memorization, it is advisable to divide all classical symptoms into two groups according to the elicitation technique:
- Percussion (“tapping”) symptoms — pain is provoked by percussion or striking a specific area.
- Palpation (“touching”) symptoms — pain occurs when pressing or sinking the fingers into the projection zone of the gallbladder and related areas.
The group of palpation symptoms is additionally divided into symptoms elicited on inspiration (respiratory) and outside the respiratory phase.
Percussion symptoms
Percussion symptoms are based on provoking pain by mechanical impact along the right costal margin or hypochondrium.
- Ortner's sign — pain upon tapping with the ulnar edge of the hand along the right costal margin. One of the most reproducible signs.
- Boas's (Volsky's) sign — pain upon an oblique strike with the ulnar edge of the hand over the right hypochondrium. Essentially analogous to Ortner's sign, but with a different point of application of force.
- Lepene's sign — vigorous percussion in the right hypochondrium increases pain in the projection of the gallbladder.
- Vasilenko's sign — percussion in the right hypochondrium at the height of inspiration causes a sharp increase in pain; at this moment, the inflamed gallbladder shifts downward and comes into contact with the palpating hand.
Palpation symptoms outside the respiratory phase
These symptoms are elicited by simple pressure at characteristic points without the patient's respiratory movements.
- Zakharyin's sign — pain upon pressing at the gallbladder projection point (the intersection of the lateral border of the right rectus abdominis muscle with the costal margin).
- Gubergrits's sign — pain upon palpation in the area of the xiphoid process. The sign is nonspecific and is frequently described also in acute pancreatitis, which is explained by the anatomical and functional connection between the biliary tract and the pancreas.
- Mussy-Georgievsky's sign (phrenic sign) — pain upon pressing between the heads of the right sternocleidomastoid muscle (m. sternocleidomastoideus). It is associated with irritation of the right phrenic nerve by the inflamed gallbladder.
Palpation symptoms on inspiration
These symptoms utilize the physiological descent of the diaphragm and liver on inspiration, during which the gallbladder moves under the palpating hand.
- Murphy's sign — the physician sinks their fingertips under the right costal margin in the projection of the gallbladder and asks the patient to take a deep breath. At the height of inspiration, sharp pain occurs, and the patient reflexively interrupts inspiration. Technically, it is a palpation analogue of Ortner's sign.
- Kehr's sign — an increase in pain during deep palpation in the right hypochondrium on inspiration. Technically close to Boas's sign, but performed via palpation rather than percussion.
Clinical significance and elicitation technique
The listed symptoms belong to the arsenal of propaedeutic examination and make it possible to suspect acute cholecystitis prior to instrumental methods. No single symptom is pathognomonic; diagnostic value increases when several signs are detected simultaneously.
The examination technique requires maintaining a sequence: first superficial abdominal palpation, then percussion tests, followed by deep palpation and provocative tests on inspiration. Pronounced muscular rigidity in the right hypochondrium and positive Murphy's and Mussy-Georgievsky's signs serve as indications for urgent ultrasound examination and surgical consultation.
One should take into account the variability of symptom names across various textbooks: the exact same sign may be attributed to different authors, so during preparation, one must cross-reference with the department's recommended textbook.
Key points
- Symptoms of acute cholecystitis are divided into percussion and palpation symptoms.
- Ortner — tapping along the right costal margin; Boas — oblique strike over the right hypochondrium.
- Lepene — vigorous percussion; Vasilenko — percussion on inspiration.
- Zakharyin — pressure at the gallbladder point; Gubergrits — at the xiphoid process.
- Murphy — sinking fingers under the costal margin with interruption of inspiration.
- Kehr — palpation of the right hypochondrium on inspiration.
- Mussy-Georgievsky (phrenic sign) — pain between the heads of the m. sternocleidomastoideus on the right.
- Diagnostic significance increases when several positive symptoms are combined.