Assessment of Courvoisier's law.

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.