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Visible Gallbladder: A Variant of the Courvoisier Sign
MEDICAL IMAGES RUNNING HEAD
Visible Gallbladder: A Variant of the Courvoisier Sign BERNARDO SOPEÑA, MD, PHD, AND JOSEFA SOUSA, MD Internal Medicine Department, Complejo Hospitalario Universitario de Vigo (Hospital Xeral-Cíes de Vigo), Pontevedra, Spain
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n 85-year-old man with severe chronic obstructive pulmonary disease was admitted to the hospital because of painless jaundice, itching, and vomiting that had begun suddenly the week before presentation. Physical examination revealed jaundice and a nontender visible mass in the right upper abdominal quadrant. The total serum bilirubin level was 12 mg/dL, and levels of transaminases and alkaline phosphatase were high. Computed tomography of the abdomen showed severe distention of the gallbladder, which was protruding the abdominal wall, along with dilatation of the common bile duct caused by a heterogeneous mass in the head of the pancreas. Magnetic resonance cholangiopancreatography confirmed the presence of a 5-cm pancreatic mass with vascular invasion. The patient refused surgery. Placement of a biliary stent produced resolution of the jaundice and itching. The patient was discharged under medical supervision.
Mayo Clin Proc.
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In 1890, Swiss surgeon Ludwig Courvoisier concluded on the basis of a prospective study of 187 cases of common bile duct obstruction that the presence of painless jaundice plus a palpable gallbladder is extremely suggestive (but not pathognomonic) of malignant obstruction.1,2 Although the accuracy of Courvoisier’s conclusions has been questioned,3 the presence of the Courvoisier sign remains a useful tool more than a century after its initial description.4 In our patient, the gallbladder was not only palpable but also visible. Whether this characteristic may add more specificity to the Courvoisier sign merits further study. 1. Verghese A, Berk SL. Courvoisier’s law [letter]. Lancet. 1986;1:99. 2. Verghese A, Dison C, Berk SL. Courvoisier’s “law”—an eponym in evolution. Am J Gastroenterol. 1987;82:248-250. 3. Watts GT. Courvoisier’s law. Lancet. 1985; 2:1293-1294. 4. Bromley PJ, Keller FS. Courvoisier’s gallbladder. N Engl J Med. 2001; 345:1542. © 2007 Mayo Foundation for Medical Education and Research
July 2007;82(7):791 •
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
791
Visible Gallbladder: A Variant of the Courvoisier Sign BERNARDO SOPEÑA, MD, PHD, AND JOSEFA SOUSA, MD Internal Medicine Department, Complejo Hospitalario Universitario de Vigo (Hospital Xeral-Cíes de Vigo), Pontevedra, Spain
A
n 85-year-old man with severe chronic obstructive pulmonary disease was admitted to the hospital because of painless jaundice, itching, and vomiting that had begun suddenly the week before presentation. Physical examination revealed jaundice and a nontender visible mass in the right upper abdominal quadrant. The total serum bilirubin level was 12 mg/dL, and levels of transaminases and alkaline phosphatase were high. Computed tomography of the abdomen showed severe distention of the gallbladder, which was protruding the abdominal wall, along with dilatation of the common bile duct caused by a heterogeneous mass in the head of the pancreas. Magnetic resonance cholangiopancreatography confirmed the presence of a 5-cm pancreatic mass with vascular invasion. The patient refused surgery. Placement of a biliary stent produced resolution of the jaundice and itching. The patient was discharged under medical supervision.
Mayo Clin Proc.
•
In 1890, Swiss surgeon Ludwig Courvoisier concluded on the basis of a prospective study of 187 cases of common bile duct obstruction that the presence of painless jaundice plus a palpable gallbladder is extremely suggestive (but not pathognomonic) of malignant obstruction.1,2 Although the accuracy of Courvoisier’s conclusions has been questioned,3 the presence of the Courvoisier sign remains a useful tool more than a century after its initial description.4 In our patient, the gallbladder was not only palpable but also visible. Whether this characteristic may add more specificity to the Courvoisier sign merits further study. 1. Verghese A, Berk SL. Courvoisier’s law [letter]. Lancet. 1986;1:99. 2. Verghese A, Dison C, Berk SL. Courvoisier’s “law”—an eponym in evolution. Am J Gastroenterol. 1987;82:248-250. 3. Watts GT. Courvoisier’s law. Lancet. 1985; 2:1293-1294. 4. Bromley PJ, Keller FS. Courvoisier’s gallbladder. N Engl J Med. 2001; 345:1542. © 2007 Mayo Foundation for Medical Education and Research
July 2007;82(7):791 •
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
791