Courvoisier's law

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Courvoisier's law (or Courvoisier syndrome, or Courvoisier's sign or Courvoisier-Terrier's sign) states that in the presence of an enlarged gallbladder which is nontender and accompanied with mild jaundice, the cause is unlikely to be gallstones. Usually, the term is used to describe the physical examination finding of the right-upper quadrant of the abdomen. This sign implicates possible malignancy of the gall bladder or pancreas and the swelling is unlikely due to gallstones.[1][2]

This observation occurs because gallstones are formed over an extended period of time, resulting in a shrunken, fibrotic gall bladder which does not distend easily. This shrunken gallbladder is less likely to be palpable on exam. In contrast, the gallbladder is more often enlarged (and more easily palpated) in pathologies that cause obstruction of the biliary tree over a shorter period of time such as pancreatic malignancy leading to passive distention from back pressure.[2] Note that a palpable tender gallbladder may be seen in acute acalculous cholecystitis, which commonly follows trauma or ischemia and causes acute inflammation of the gallbladder in the absence of gallstones.

More concisely, tumors that obstruct the common bile duct result in an enlarged gallbladder. In contrast, obstructing stones do not result in an enlarged gallbladder as the gallbladder is often too scarred (i.e. fibrotic) to allow enlargement.

Note that Courvoisier's original observations, published in Germany in 1890, were not originally cited as a 'law', and no mention of malignancy was made. These points are commonly missquoted or confused in the medical literature.[3]

Exceptions to Courvoisier's law implies that a stone is responsible for jaundice and a non-tender, palpable gall bladder. Typically gall bladder stones form slowly which allow time for the gall bladder to become tender. The exceptions to the law are stones that dislodge and acutely jam the duct distally to the hepatic/cystic duct junction:

  1. Gallstone falling and blocking the Ampulla of Vater
  2. Gallstone falling and blocking the cystic/hepatic duct junction

Cholangiocarcinoma, Klatskin tumors, ascariasis, or oriental hepatitis are not exceptions to the law because they all fall under it. The law simply says that jaundice and non-tender, palpable gall bladders are caused by other things than chronic bile stone formation. The law does not say that these symptoms automatically mean pancreatic cancer. It just happens that pancreatic cancer is the most common cause that falls under Courvoisier's law.

It is named for Ludwig Georg Courvoisier.[4]

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References[edit]

  1. ^ Parmar MS (April 2003). "Courvoisier's law". CMAJ 168 (7): 876–7. PMC 151998. PMID 12668550. 
  2. ^ a b Lawrence, Peter F. (2006). Essentials of General Surgery. Lippincott Williams & Wilkins. ISBN 0-7817-5003-2. 
  3. ^ Fitzgerald, J Edward F; White Matthew J, Lobo Dileep N (Apr 2009). "Courvoisier's gallbladder: law or sign?". World journal of surgery (United States) 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. ISSN 0364-2313. PMID 19190960. 
  4. ^ synd/2065 at Who Named It?

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