The Clinical Picture

The Courvoisier sign

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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.

Figure 1. Computed tomography shows a pancreatic mass (white arrow) causing dilatation of the bile duct (red arrow) and a severely distended and elongated gallbladder (blue arrow).

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.

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