| Abstract|| |
Courvoisier's Law is frequently interpreted as "A palpable gallbladder is a sign of malignancy". In fact, it is the most misquoted signs as he was referring to common duct obstruction by stones and other problems, without specifying malignancy ! In a retrospective study of 86 cases of distended gallbladder between 1987 and 1992, we assessed the validity and the accuracy of this law in the diagnosis of bilio-pancreatic diseases, by matching the finding of a palpable gallbladder by clinical examination (46 cases: 53%), with CT scan (75 cases: 87%), and by operative surgery (82 cases: 95%). In four cases, a palpable gallbladder spontaneously resolved before the surgical act. In 17 cases, repeated palpation of the gallbladder by several medical students or residents in one session, resulted in disappearance of the mass under the fingers of the last examiner. In 13 of these 17, a palpable gallbladder was again present after 3-7 days of its disappearance. With the new imaging technology, we may apply the implications of Courvoisier's Law to any obstruction of the distal common bile duct below the cystic duct, the ampulla of Vater, and the head of pancreas. We found this obstruction may be caused by malignancy in 87% and inflammation and lithiasis in 13%. A tumor or other obstruction above the cystic duct, will not cause distention of the gallbladder.
|How to cite this article:|
Munzer D. Assessment of Courvoisier's law. Saudi J Gastroenterol 1999;5:106-12
In 1890, Ludwing G. Courvoisier, a Swiss surgeon from Basel wrote his famous law or sign in his book  : [Figure - 1]. "With obstruction of the common bile duct by stone, dilatation of gallbladder is rare. The organ is usually shrunken. With obstruction of other kinds, on the contrary, distention is the rule, shrinking occurs in only one twelfth of these cases"  . Courvoisier did not mention which part of the common bile duct (CBD) is affected by the obstruction to generate a palpable gallbladder (PGB), nor he did determine the various pathologies causing a PGB, by using a generalized term "other kinds". In the meantime and until the eighties, Courvoisier's Law has stood the test of time rather well  until the advent of the new imaging studies: ultrasonography (US), computerized axial tomography (CT), corroborated with the endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). The new technology has proved the necessity of a new assessment of this law standing for more than one century. With these advanced investigations and procedures  , we could trace a complete map of the whole biliary tract, localizing the effect of every lesion, at each level of the CBD and the biliopancreatic confluent, which may cause a constant or inconstant distention of the gallbladder (GB), considering a possible painless distended GB or painful PGB, as we may find in some patients with biliary lithiasis.
| Patients and methods|| |
In a retrospective study of 86 selected cases of distended GB, monitored by physical examination, CT scan and proved by laparotomy, between 1987 and 1992, we could assess the value of a distended GB in determining the explicit etiology of obstructive jaundice which was present in 81 patients (94%) and we could evaluate the importance of this clinical sign in making the correct diagnosis by matching the palpability of the GB in physical examination, with the imaging in CT scan and the finding in subsequent surgery, in order to estimate the validity of Courvoisier's Law. From these proven 86 cases of distended GB, 46 patients (53%) have a palpable GB by physical examination. The palpability has disappeared in four cases when they have reached the day of surgery. In 29 cases (34%), CT scan has revealed a distended GB not felt by simple physical examination. In 11 cases (13%), only at the surgical act, we could notice the presence of a distended GB, not revealed by physical examination, and unseen in CT scan [Table - 1]. In all these 86 cases, we have either an intrinsic obstruction or extrinsic compression of the distal part of the CBD.
| Results|| |
Palpation of GB has been found painless or painful, constant or inconstant, according to the causal pathology. PGB is possible in any obstruction of the distal part of the CBD, below the cystic duct, and the bilio-pancreatic confluent.
Painless PGB is encountered mostly in the cancer of the head of pancreas [Figure - 1], it is rare in chronic pancreatitis, but very possible in benign and malignant growth of the ampulla of Vater [Figure - 3]. It is often encountered in malignant obstruction of the distal CBD [Figure - 4]. Five cases of distended GB were detected clinically in acalculous cholecystitis (4 cases) and in chronic pancreatitis (one case).
Painless GB could be detected on one examination and not on another. In 17 cases, the consecutive repeated palpation of the GB by several medical students or residents in one session, resulted in disappearance of the palpable mass  under the fingers of the last examiner. Squeezing of the GB may lead to a gradual passage of bile through the narrowed CBD. In 13 cases, a PGB was again present after 3-7 days. In some cases, even without squeezing the GB, the palpability may disappear, if an impacted cystic duct stone falls back into the GB or passes in the CBD, relieving the obstruction at the cystic duct neck and removing the obstruction of drainage of the GB  . In addition, a movable stone in the distal CBD or tumor necrosis in the lumen of the lower CBD or around the ampulla of Vater, or small malignant lesions in the head of pancreas may allow the passage of bile by squeezing the GB and therefore may explain the fading of a PGB [Table - 2] & [Table - 3]. Painful PGB is seen mostly in acute cholecystitis, associated with obstruction of the cystic duct by a stone with hydrops or empyema [Figure - 5] [Table - 4].
The palpability of the GB in the physical examination and the Distension of GB in CT scan, with and without jaundice, is considered an important physical sign related to some degree of intrinsic obstruction or extrinsic compression of the distal CBD. The new imaging technology (US or CT) may reveal a distended GB when it cannot be felt sometimes by physical examination, offering a more accurate evaluation of Courvoisier's Law. On the opposite, a high obstruction of the hepatic hilus and proximal CBD may prevent bile from entering the cystic duct and the usual mechanism responsible for the filling of the GB is thus interfered with  . In this case, the CT scan of the liver and upper abdomen, may not display the retracted GB, but may visualize a dilatation of the intra-hepatic ducts only , [Figure - 6].
| Discussion|| |
In the diagnosis of cancer of the head of pancreas, we used to rely on the gastroduodenal radiography to detect an inverted three (Frostberg's sign) in the second duodenum or an enlargement of the duodenal loop. An imprint of distal CBD on the bulb and duodenum [Figure - 7] could be the outcome of any obstruction in the bilio-pancreatic confluent. The clinical usefulness of Courvoisier's Law has suffered from too many apparent exceptions explainable in terms of the presence or absence of chronicity and/or high grade obstruction. With the available imaging technology, we have a valuable and more accurate method to assess this law.
Kalser et al have well stated that Courvoisier's Law is not inviolable as with most laws and absence of PGB by no means, excludes the diagnosis of neoplastic obstacles  . Orloff relates that in carcinoma of the CBD, patient may have jaundice and hepatomegaly, but one third only has a PGB  Scherlock  says that GB is only felt in about half the patients, although at subsequent laparotomy, a dilated GB is found in three quarters of cases. Ingelfinger  found that at autopsy or operation, enlarged and tense GB in present in four fifths of the cases. According to Palmer  , PGB is encountered in third of the patients with cancer of the head of pancreas, in 9% in patients with biliary lithiasis. Viteri  found that prior to surgery, the GB is palpable in 25% of patients with cancer of pancreas and 16.1% in icteric patients with choledocholithiasis. Kaver  and schnedorf  noted a PGB in less than 10% of jaundiced patients with cancer of the ampulla of Vater or pancreatic head.
There is a marked discrepancy between the total number of PGB detected by physical examination and the number found to be distended by physical examination and the number found to be distended in new imaging devices or in surgery. While this may be explained in part by lack of sufficient care on the part of the examiner, it is also true that a dilated GB may escape notice in the case of thick abdominal wall, especially when there is marked enlargement of the right lobe of the liver with overlapping of the GB, but imaging studies do not make this possible error. Another important diagnostic factor in the PGB, is the possible disappearance of this mass  after repeated successive palpation, squeezing the GB little by little. This intermittent pressure may dislodge the causal obstacle, changing the obstruction from complete to incomplete, allowing a gradual passage of bile through the CBD and therefore emptying the GB. The disappearance of a PGB is usually temporary, as the bile accumulates in the GB, above the level of obstruction, localized below the cystic duct.
In a mechanical obstructive jaundice, the triad of icterus, hepatomegaly and itching, could be caused by an extrinsic compression of the CBD (cancer of the head of pancreas, lymphatic nodes in the hepatic hilus) or by an intrinsic obstruction (stones, sludge, growth, parasites mostly ascaris). Review of the literature indicates that on the whole, a distended GB can be detected clinically in about half the cases of pancreatic cancer with jaundice , , however, in every distension of the GB due to any type or obstruction of the CBD, it is important to delimit the level and degree of obstruction, by specifying a rigid rule: Any obstruction of the CBD below the cystic duct may generate a distension of the GB, but if the obstruction is in the proximal CBD, above the cystic duct, the GB may shrink [Figure - 8]. In a case of PGB, with mild jaundice and loss of weight, not included in this study as it is before the advent of CT scan, the diagnosis was hydro-cholecystitis, but we were surprised at surgery, to find a mild dilatation of the biliary tract, with small focal mass in the periampullary area, to be detected only by deep palpation of the pancreas by the surgeon.
| Conclusion|| |
We don't agree with the total rejection of Courvoisier's Law , , but we agree  that Courvoisier's Law, sign or phenomena is rarely given as he wrote it. We may conclude that Courvoisier's
Law has to be rectified by delimiting the importance of the level of intrinsic obstruction and extrinsic compression of the distal CBD which may generate a distension of GB, detectable mostly either by physical examination or by imaging studies. Various pathologies leading to a distended GB and referred by Courvoisier as "other kinds" may implicate a complete obstruction below the cystic duct. Temporary disappearance of a PGB suggests incomplete obstruction of the distal CBD by a movable stone, parasites (ascaris) and tumoral necrosis. On the other hand, any obstruction above the cystic duct, in the proximal BD or the hepatic hilus, may prevent the bile from reaching the GB and the usual mechanism responsible for its filling in no more applicable.
Needless to say that the imaging technology has added tremendously to our clinical perception of the palpability of the GB in biliopancreatic diseases. With the help of one or more from these imaging studies: US, CT scan, ERCP, PTC, it is easy to evaluate and assess accurately all the various pathological findings, before performing any type of surgery.
| Acknowledgment|| |
The author is grateful to Dr. James L. Achord from the University of Mississippi Medical Center for his valuable help in writing the manuscript.
| References|| |
|1.||Courvoisier LG. The pathology and surgery of the biliary tract, Leipzig, FCW Vogel. 1890;58. |
|2.||Ransom HK. Carcinoma of Pancreas. Am J of Surg 1928;40:246-81. |
|3.||Palmer ED. Clinical Gastroenterology, Washington, D. C. Hoeber-Harper. 1957;526-64. |
|4.||Matzen P, Malchow-Moeller A, Brun B, et al. Ultrasonogrphy and choloscintigraphy in suspected obstructive jaundice. A prospective comparative study, Gastroenterology 1983;84:1492-7. |
|5.||Munzer D. Evaluation of the fading of a non tender palpable gallbladder in the diagnosis of obstructive jaundice. Gastroenterology 1992;102:A324. |
|6.||Shaffner F. Tests related to the liver, Bockus Gastroenterology, Philadelphia, W. B. Saunders Company, Fourth Edition 1985;1:410-26. |
|7.||Munzer D. The meaning of non-visualization of gallbladder in comutarized axial tomography of the liver in obstructive jaundice. Gastroenterology 1994;104:A351. |
|8.||Wright T, Millward-Sadler GH, Alberti KGMM, Karran S. Liver and Biliary Diseases, London, Balliere Tindall, W. B. Saunder's Company 1985;1433-62. |
|9.||Kaiser MH, Smith FP, Schein SP, Zeppa R, Exocrine Tumors of the Pzncreas, Bockus Gastroenterology, Philadelphia, W. B. Saunders Company, Fourth Edition 1985;6:4094-109. |
|10.||Orloff MJ, Marassi NP, Tumors of the extra-hepatic bile ducts, Bockus Gastroenterology, Philadelphia, W. B. Saunders Company, Fourth Edition 1985;6:3771-81. |
|11.||Scherlock S. Dooley J. Diseases of the liver and biliary system, London, Blackwell Scientific Publications, Ninth Edition 1993;600. |
|12.||Ingelfinger FJ. The diagnosis of cancer of the pancreas, New Eng J Med 1946;235:653. |
|13.||Viteri AL, Courvoisier's Law and Evaluation of the jaundiced patient. Texas Med1980;76:60-1. |
|14.||Kauer JT, Glenn F. Carcinoma of the pancreas. Arch Surg 1941;42:141-55. |
|15.||Schnedorf JG, Orr TG. Fifty two proven cases of carcinoma of pancreas and ampulla of Vater, with special references to carcinoma. Ann Surg 1941;114:603-11. |
|16.||Brunschwing A, Surgical treatment of carcinoma of body of pancreas. Ann Surg 1944;120:406-16. |
|17.||Lieber MM, Stewart HL, Lund H. Carcinoma ofperipapillary portion of the duodenum. Ann Surg 1929;109:219-45 & 383-429. |
|18.||Watts GT. Courvoisier's Law, Lancet 1985;2:1293-4. |
|19.||Verghese A, Dison C, Berk SL. Courvoisier's Law, An eponyme in evolution. Am J Gastroenterol 1987;82:248-50. [PUBMED] |
|20.||Morgenstern L, Ludwing G. Courvoisier and Courvoisier's Law. Surg Gynec Obstet 1960;110:383-4. |
Professor of Medicine, Mouassat University Hosptial, P.O. Box 2225, Damascus, Syria
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]