Courvoisier's Law in Obstructive Jaundice

Clinical Significance and Diagnostic Approach

• The presence of a palpable gallbladder with jaundice, known as Courvoisier's sign, suggests malignancy rather than choledocholithiasis, with a reported association with malignancy in approximately 87% of cases 1
• Initial evaluation of patients with Courvoisier's sign should include abdominal ultrasound to confirm gallbladder distention and biliary dilation, as recommended by the American College of Radiology 2, 3, 4
• Laboratory tests, including total and fractionated bilirubin, complete blood count, and liver enzymes (AST, ALT, ALP, GGT), are essential in the diagnostic approach, with elevated alkaline phosphatase being particularly indicative of biliary obstruction, as suggested by the American College of Radiology 5
• Further imaging with CT or MRCP is recommended to identify the cause of obstruction, with CT being highly sensitive (74%-96%) and specific (90%-94%) for detecting biliary obstruction, according to the American College of Radiology 4
• ERCP may be considered both for diagnosis and potential therapeutic intervention if malignancy is suspected, as recommended by the American College of Radiology 3, 6
• The American College of Gastroenterology recommends expedited investigation for pancreatic or biliary tract malignancy when Courvoisier's sign is present, with a focus on patients with adult-onset diabetes without predisposing factors 1