The Courvoisier sign

A 60-year-old woman has had jaundice, dark-colored urine, and light-colored stools for the past several days. She has no history of jaundice or gallstone disease.

With the exception of a palpable gallbladder, the physical examination of the abdomen is unremarkable. Computed tomography of the abdomen reveals a mass in the head of the pancreas, a dilated proximal biliary duct, and a severely distended and elongated gallbladder (Figure 1).

Over a century ago, Courvoisier observed that a palpable gallbladder in a patient with obstructive jaundice is often caused by a non-calculus abnormality of the biliary system, such as pancreatic cancer or cholangiocarcinoma, distal to the insertion of the cystic duct.^1–4 He attributed his findings to a higher likelihood of fibrosis of the gallbladder, with stone disease rendering it less distensible.⁴

,

Although often associated with malignancy, the Courvoisier sign can also be seen in benign processes causing obstruction of the common bile duct.⁵

For decades after its initial description, the Courvoisier sign was used as an important sign for the differential diagnosis of jaundice, but advances in diagnostic imaging have led to a more accurate and earlier diagnosis with less reliance on this sign. In this patient, tissue diagnosis confirmed a clinical suspicion of pancreatic adenocarcinoma.