Courvoisier's law
Encyclopedia
Courvoisier's law 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 implicated possible malignancy of the gall bladder or pancreas and the swelling is unlikely due to gallstone
s.
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 backpressure. 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 (ie 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.
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:
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
.
Gallbladder
In vertebrates the gallbladder is a small organ that aids mainly in fat digestion and concentrates bile produced by the liver. In humans the loss of the gallbladder is usually easily tolerated....
which is nontender and accompanied with mild jaundice
Jaundice
Jaundice is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae , and other mucous membranes caused by hyperbilirubinemia . This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid...
, 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 implicated possible malignancy of the gall bladder or pancreas and the swelling is unlikely due to gallstone
Gallstone
A gallstone is a crystalline concretion formed within the gallbladder by accretion of bile components. These calculi are formed in the gallbladder, but may pass distally into other parts of the biliary tract such as the cystic duct, common bile duct, pancreatic duct, or the ampulla of...
s.
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 backpressure. Note that a palpable tender gallbladder may be seen in acute acalculous cholecystitis
Cholecystitis
-Signs and symptoms:Cholecystitis usually presents as a pain in the right upper quadrant. This is known as biliary colic. This is initially intermittent, but later usually presents as a constant, severe pain. During the initial stages, the pain may be felt in an area totally separate from the site...
, which commonly follows trauma or ischemia
Ischemia
In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
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 (ie 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.
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:
- Gallstone falling and blocking the Ampula of Vater
- Gallstone falling and 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
Ludwig Georg Courvoisier
Ludwig Georg Courvoisier was a surgeon from Basel, Switzerland. He was one of the first doctors to remove gallstones from the common bile duct....
.