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| CASE REPORT |
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| Year : 2021 | Volume
: 7
| Issue : 2 | Page : 148-150 |
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An unusual finding of Courvoisier sign: Gallstone with locally advanced carcinoma gallbladder
Jayabal Pandiaraja
Department of General Surgery, Dr. Mehta Hospital Global Campus, Chennai, Tamil Nadu, India
| Date of Submission | 26-Nov-2020 |
| Date of Decision | 28-Jun-2021 |
| Date of Acceptance | 11-Aug-2021 |
| Date of Web Publication | 30-Dec-2021 |
Correspondence Address:
Jayabal Pandiaraja
26/1, Kaveri Street, Rajaji Nagar, Villivakkam, Chennai - 600 049, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcrsm.jcrsm_83_20
Courvoisier sign is one of the important clinical signs used in the diagnosis of hepatobiliary disease. According to this sign, when the gallbladder is palpable in a jaundiced patient, it is unlikely due to stone. There are exceptions for Courvoisier signs such as double impacted stone, oriental cholangitis, and AIDS-associated cholangiopathy. In our case, there is a gallstone with palpable gallbladder due to concurrent occurrence of gallstone with gallbladder carcinoma compressing the adjacent biliary tree.
Keywords: Courvoisier sign, gallbladder carcinoma, gallstone, palpable gallbladder
How to cite this article:
Pandiaraja J. An unusual finding of Courvoisier sign: Gallstone with locally advanced carcinoma gallbladder. J Curr Res Sci Med 2021;7:148-50 |
How to cite this URL:
Pandiaraja J. An unusual finding of Courvoisier sign: Gallstone with locally advanced carcinoma gallbladder. J Curr Res Sci Med [serial online] 2021 [cited 2022 Jan 17];7:148-50. Available from: https://www.jcrsmed.org/text.asp?2021/7/2/148/334465 |
| Introduction | |  |
The Courvoisier sign was described by Ludwig George Courvoisier in 1890 in his book called “Casuistisch-Statistische Beitrage Zur Pathologie and Enirurgie Der Gallenwege” (The pathology and surgery of the gallbladder) after he made an observation of gallbladder in various gallbladder pathologies.[1] Ludwig George Courvoisier was the first surgeon to perform successful choledochotomy and cholecystectomy. According to Courvoisier's observation “with obstruction of common bile duct by a stone, the dilation is rare. The gallbladder is usually well shrunken with obstruction, for other kinds of disease, the distension is the rule.” If the gallbladder is palpable in a jaundiced patient, it is unlikely to be due to gallstone because stones would have given rise to chronic inflammation and subsequently fibrosis of the gallbladder, therefore rendering it incapable of dilatation. On contrary, gallbladder pathology other than stone would result in distension of the gallbladder which is felt on abdominal examination.[2]
| Case Report | | |
A 75-year-old male patient presented with complaints of loss of appetite and loss of weight for 2 months' duration. He also had a generalized weakness, passing high-colored urine, and yellowish discoloration of eyes for a 1-month duration. He described on-and-off abdominal pain and generalized pruritus for 1 month. The patient denied a history of recent blood transfusion, jaundice, and using any other medications. On examination, he was emaciated and thin built. The general examination showed yellowish discoloration of eyes with scratch marks all over the body. Abdominal examination showed a soft, nontender globular lump palpable in the right hypochondrium. There was no evidence of any other mass in the abdomen.
On investigation, the patient's hemoglobin was 7.0 g%. The renal function test and viral markers were normal. Liver function test showed serum total bilirubin - 7.2 mg/dl, direct bilirubin - 6.5 mg/dl, aspartate aminotransferase - 108 U/L, alkaline phosphatase - 86 U/L, alkaline phosphatase - 501 U/L, and gamma glutamyltransferase - 390 U/L. Computed tomography with oral and intravenous contrast showed significantly enlarged gallbladder with irregular thickened mass. There were multiple small and large calculi seen in the gallbladder [Figure 1]. The mass compresses the common hepatic duct and proximal part of the common bile duct produces significant dilation of gallbladder and intrahepatic biliary radicals [Figure 2]. There were multiple lymph nodes seen in the peripancreatic, celiac trunk, precaval, preaortic, paracaval, paraaortic, and interaortic caval region. He was diagnosed with cholelithiasis with metastatic gallbladder carcinoma and planned for palliative care.
| Discussion | | |
According to Courvoisier sign, gallstone produces intermittent obstruction and malignancy produces constant obstruction.[3] The malignancy produces significant dilatation due to high back pressure by a rapidly growing mass. Gallstones may cause only partial obstruction created to a ball valve action, leading to less consistent intraductal pressure elevation.[4]
The following are the exceptions for the Courvoisier sign, which includes (1) oriental cholangitis, (2) cystic duct strictures, (3) ascaris infestations, (4) stone in both cystic duct and common bile duct, (5) multiple gallstones with large common bile duct stone, (6) AIDS-associated cholangiopathy, (7) diet-induced cholecystitis, (8) pancreatic calculous obstructing the ampulla, (9) pancreatic or periampullary carcinoma in a patient with prior cholecystectomy, (10) Mirizzi's syndrome, (11) portal lymphadenopathy, and (12) stone in Hartmann pouch.[5]
The sensitivity and specificity of Courvoisier sign for malignancy range from 26% to 55% and 83% to 90%, respectively.[5] The problem with the Courvoisier sign is, he didn't mention which part of the common bile duct should be obstructed to produce palpable gallbladder and he didn't mention the various pathologies causing palpable gallbladder in his discription.[6] Courvoisier sign depends on the following factors which include (1) presence or absence of chronicity, (2) grade of obstruction, (3) level of obstruction, (4) states of the cystic duct, (5) nature of disease, (6) the number of examinations, and (7) experience of the surgeon.[7]
In our case even with the presence of gallstone, there is dilatation of the gallbladder. However, according to Courvoisier sign, if the gallbladder is palpable, it is unlikely due to gallstone. In our case, there are concurrent stone and malignant pathology. The dilatation of the gallbladder in our case is due to compression proximal part of the common bile duct by carcinoma gallbladder. The take-home message here is, Courvoisier sign is one of the important signs in the hepatobiliary system used when imaging modality is not available. With currently available imaging modality, the utility of the Courvoisier sign is limited. However, still, the sign holds its position for the initial clinical diagnosis of biliary disease. Even in the presence of stone in the gallbladder, dilation of the gallbladder occurs when it is associated with carcinoma gallbladder.
| Conclusion | | |
In our case, there is a gallstone with palpable gallbladder due to concurrent occurrence of gallstone with locally advanced gallbladder carcinoma compressing the adjacent biliary tree. On contrary to the Courvoisier sign, even with gallstone, there may be dilatation of the gallbladder. In our case, the gallbladder carcinoma causes compression of common hepatic duct and proximal part of common bile duct which produces jaundice and palpable gallbladder.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Parsi MA. The Courvoisier sign. Cleve Clin J Med 2010;77:265. |
| 3. | Fitzgerald JE, White MJ, Lobo DN. Courvoisier's gallbladder: Law or sign? World J Surg 2009;33:886-91. |
| 4. | Memon AA, Soomro MI, Soomro QA. Courvoisier's law revisited. J Coll Physicians Surg Pak 2012;22:392-4. |
| 5. | Chandramohan SM, Madhusudhanan J, Anbazhagan A, Duraisamy B, Dhalla BY, Chandrasekaran S. Common bile duct stone with Mirizzi's syndrome: Another exception to double duct sign and Courvoisier's law? Internet J Surg 2012;28:1-5. Available from: http://ispub.com/IJS/28/2/14003. [Last accessed on 2019 Aug 03]. |
| 6. | Gorelik O, Shteinschnaider M, Cohen N, Almoznino-Sarafian D. Visible Courvoisier's sign: A rare presentation of bile duct obstruction. Harefuah 2013;152:516-7, 565. |
| 7. | Agrawal S, Vohra S. Simultaneous Courvoisier's and double duct signs. World J Gastrointest Endosc 2017;9:425-7. |
[Figure 1], [Figure 2]
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