Courvoisier's law states that in a patient with painless jaundice, a palpable gallbladder is unlikely to be due to gallstones. The reasoning is about the gallbladder wall, not the stone: years of stone-related inflammation leave it thickened and fibrotic, so it cannot distend. A healthy, thin-walled gallbladder obstructed from below by a tumour can balloon, and becomes smooth, rounded and palpable.
What to feel for
A palpable gallbladder sits at the tip of the right ninth costal cartilage. It is:
- Smooth and rounded, not craggy
- Non-tender — tenderness suggests inflammation instead
- Moves with respiration, because it hangs from the liver
- You cannot get above it
- Dull to percussion
Found alongside painless, progressive jaundice with weight loss, this points to a malignant obstruction of the distal bile duct — pancreatic head carcinoma, an ampullary tumour or a distal cholangiocarcinoma.
The exceptions
The law says "unlikely", not "never". It fails when a healthy gallbladder meets a stone it never had time to scar against:
- A stone forming in the common bile duct itself (a primary duct stone), leaving the gallbladder unscarred.
- Double impaction — one stone lodged in the cystic duct and another in the common bile duct.
- Mirizzi syndrome, where a stone in the cystic duct or Hartmann's pouch compresses the common hepatic duct from outside.
In practice imaging decides. The law is a way of directing your suspicion, not a substitute for an ultrasound.
Say it precisely in the OSCE
Weak version: "a palpable gallbladder means cancer." Strong version: "In a jaundiced patient without pain, a palpable gallbladder makes gallstones unlikely, because a gallbladder chronically inflamed by stones is fibrotic and cannot distend. I would be concerned about a malignant distal bile duct obstruction and would arrange an ultrasound."
The related signs
| Sign | What it is | What it suggests |
|---|---|---|
| Murphy's sign | Two fingers under the right costal margin; the patient breathes in and stops with pain. Negative on the left. | Acute cholecystitis. Less reliable in the elderly. |
| Troisier's sign | Palpable left supraclavicular node (Virchow's node) | Upper gastrointestinal or pancreatic malignancy |
| Sister Mary Joseph nodule | Umbilical metastatic nodule | Intra-abdominal malignancy |
| Charcot's triad | Fever with rigors, right upper quadrant pain, jaundice | Ascending cholangitis — an emergency |
| Reynolds' pentad | Charcot's triad plus hypotension and confusion | Severe cholangitis needing urgent drainage |
Don't forget the scars
A previous cholecystectomy does not rule out stones. Retained or recurrent common bile duct stones are a common cause of jaundice months or years later, and after recent surgery a bile duct injury should also cross your mind. Always look for scars before you start palpating.