Courvoisier’s Sign

Modern interpretation and limitations

Modern studies using cross-sectional imaging (e.g. MRCP) have re-evaluated Courvoisier’s findings. Murphy et al. (2012) showed statistically significant differences in gallbladder volumes on MRCP:

• Larger volumes with malignant obstructions
• Smaller or non-distended gallbladders with gallstone disease

Objective measurement…appears to validate Courvoisier’s sign as a valuable clinical sign, even in the era of advanced imaging

Murphy 2012

However the sign lacks sensitivity (26–55%) but has moderate to high specificity (83–90%) for malignancy. Exceptions include:

• Hydropic gallbladder with impacted stone (Mirizzi’s syndrome)
• Chronic autoimmune pancreatitis
• Parasitic obstruction
• Choledochal cysts

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History of the Courvoisier Sign

1888 – Louis Bard (1857–1930) and Adrien Ferdinand Pic (1863–1943) described a clinical triad characteristic of carcinoma of the head of the pancreas, based on their extensive clinical and pathological observations. The Bard–Pic Syndrome includes:

1. Progressive obstructive jaundice
2. Palpable, enlarged gallbladder (now associated with Courvoisier’s sign)
3. Rapid cachexia with severe anorexia and weight loss

While the term “Bard–Pic syndrome” is largely obsolete, it foreshadowed the modern understanding of pancreatic head malignancy and anticipated Courvoisier’s observations regarding gallbladder enlargement in malignant obstruction.

1889 – Louis-Félix Terrier (1837–1908), a leading French surgeon at Hôpital Bichat, described a case of extrahepatic biliary obstruction in a patient with a distended gallbladder but no evidence of gallstones, treated surgically via one of the earliest successful cholecystenterostomy procedures. Terrier’s clinical observations of gallbladder distension in malignant obstruction predated the principle later popularized as Courvoisier’s Law.

En présence de ces troubles menaçants, dus très certainement à une oblitération du canal cholédoque, avec dilatation anormale de la vésicule biliaire, on se décida à intervenir.

In the face of these alarming symptoms, very likely due to an obstruction of the common bile duct, with abnormal dilation of the gallbladder, it was decided to operate

Terrier 1889

1890 – Swiss surgeon Ludwig Georg Courvoisier (1843–1918) published Casuistisch-statistiche Beiträge zur Pathologie und Chirurgie der Gallenwege. Based on 187 cases of common bile duct (CBD) obstruction, he observed:

• Gallstone-related CBD obstruction was frequently associated with a fibrosed, shrunken gallbladder due to prior episodes of cholecystitis. In 87 cases of common bile duct obstruction by stones, 70 had atrophied gallbladders (80.4%).
• Non-stone-related obstructions (e.g., malignancies) more often led to a distended gallbladder due to gradual ductal compression and a compliant, non-inflamed gallbladder wall. In 100 cases of non-stone obstruction, 92 had dilated gallbladders.

Notably, Courvoisier never explicitly stated this was a “law” but suggested this observation might aid in differential diagnosis if further confirmed.

1892 – Bernhard Naunyn (1839-1925) in Klinik der Cholelithiasis treats Courvoisier’s observation as established fact, reinforcing its diagnostic value in distinguishing stone from tumour obstruction.

Courvoisier was the first to observe this ; he remarked very truly that the frequent absence of distension of the gall bladder in chronic jaundice from gall-stones is of importance for the diagnosis of the condition, since in chronic biliary obstruction due to new growths of the common duct or pancreas such distension is much less frequently wanting.

Naunyn 1892

1897 – Émile Auguste Forgue (1860‑1943) introduced the term “Courvoisier–Terrier sign”. Drawing on the observations of Courvoisier and Terrier he formalised the clinical distinction between malignant and lithiasic causes of biliary obstruction.

Le signe de Courvoisier-Terrier, à savoir l’atrophie de la vésicule biliaire en cas de lithiase, sa dilatation en cas d’obstruction cancéreuse, est un signe sûr dans la majorité des cas.

The Courvoisier-Terrier sign, namely gallbladder atrophy in cases of gallstones and dilation in cases of cancerous obstruction, is a reliable sign in the majority of cases.

Forgue 1897

1899 – Hans Kehr (1862-1916) in Anleitung zur Erlernung der Diagnostik der einzelnen Formen der Gallensteinkrankheit confirms the same clinical pattern:

To the results of palpation. In obstruction of the choledochus by a stone the gall-bladder is usually small and not to be felt ; in obstruction by tumor, usually to be felt as a large and elastic distended tumor under the right ribs.

Kehr 1899

1901 – Richard Clarke Cabot (1868-1939) formally introduced the term “Courvoisier’s Law” after analyzing data from Courvoisier, Kehr, Mayo Robson, Naunyn, and 86 cases from Massachusetts General Hospital (finding only 4 exceptions). He affirmed its diagnostic value in distinguishing malignant from calculous bile duct obstruction, highlighting its relevance in cases of painless jaundice with a palpable gallbladder.

This rule of Courvoisier’s has often been stated before, but I do not find it elsewhere named as his law. It seems to me a real help in diagnosis, and I venture to name it thus

Cabot, 1901

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Associated Persons

• Ludwig Georg Courvoisier (1843–1918)
• Bernhard Naunyn (1839-1925)
• Hans Kehr (1862-1916)
• Richard Clarke Cabot (1868-1939)

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Alternative names

• Courvoisier’s law / rule / sign
• Courvoisier–Terrier sign (ref. Louis-Félix Terrier, 1837–1908)
• Courvoisier syndrome
• Courvoisier gallbladder
• Bard-Pic syndrome

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References

Historical references

• Bard L, Pic A. Contribution a l’étude clinique et anatomo-pathologique du cancer primitif du pancréas. Revue de médecine, 1888; 8: 257-282, 363-405.
• Terrier LF. Remarques cliniques sur un cas d’obstruction du canal cholédoque. Revue de chirurgie. 1889; 9: 973-981
• Courvoisier LG. Casuistisch-statistiche Beiträge zur Pathologie und Chirurgie der Gallenwege. 1890
• Naunyn B. Klinik der Cholelelithiasis. 1892 [Translated: A treatise on cholelithiasis. 1896]
• Kehr H. Anleitung zur Erlernung der Diagnostik der einzelnen Formen der Gallensteinkrankheit; auf Grund eigener, bei 433 Gallensteinlaparotomien gewonnener Erfahrungen. 1899 [Translation: Kehr H. Diagnosis of gallstone disease. 1901]
• Forgue E. Indications du traitement chirurgical dans la lithiase et les infections des voies biliaires. Gazette hebdomadaire de médecine et de chirurgie 1897; 101: 1201-1207 [Courvoisier–Terrier sign]
• Cabot RC. Courvoisier’s law. Medical News 1901; 79(22): 844-845 [Courvoisier’s law]

Eponymous term review

• Chung RS. Pathogenesis of the “Courvoisier gallbladder”. Dig Dis Sci. 1983 Jan;28(1):33-8.
• Parmar MS. Courvoisier’s law. CMAJ. 2003 Apr 1;168(7):876-7. 
• Fitzgerald JE, White MJ, Lobo DN. Courvoisier’s gallbladder: law or sign? World J Surg. 2009 Apr;33(4):886-91.
• Murphy K, McLaughlin P, O’Connor BR, Breen M, O’Súilleabháin C, Maceneaney P, Maher MM. Does Courvoisier’s sign stand the test of time? Clin Radiol. 2012 Nov;67(11):e27-30.
• Rastogi V, Singh D, Tekiner H, Ye F, Kirchenko N, Mazza JJ, Yale SH. Abdominal Physical Signs and Medical Eponyms: Physical Examination of Palpation Part 1, 1876–1907. Clinical Medicine & Research. 2018 Dec 1;16(3-4):83-91.
• Giambelluca D, Dimarco M, Salvaggio G, Madiri M. The Courvoisier’s sign. Abdom Radiol 2019; 44: 1185–1186