235 A case of Painless Palpable Gall bladder - a rare Exception of the Courvoisier's Law

Abstract

Abstract Introduction The Courvoisier's law states that a painless palpable enlarged gallbladder with jaundice is unlikely to be caused by gallstones. There are however various exceptions to the law. We report a rare case of such an exception to make us aware of the clinical condition. Case Description 72-year-old male, otherwise fit and healthy, presented to the Emergency department with epigastric discomfort, along with dark urine and pale-coloured stool. He was clinically examined to have jaundice, and a painless globular palpable gall bladder, with blood results confirming obstructive picture i.e. raised bilirubin (70 μmol/L), ALT (103 U/L) and Alkaline Phosphatase (590 IU/L). Ultrasound abdomen showed acute cholecystitis. CT chest-abdomen-pelvis showed cholelithiasis and choledocolithiasis with dilated common bile duct (CBD), as well as asymmetric gallbladder wall thickening. The MRCP showed concentric and uniform thickening of the entire gallbladder wall, with minimal pericholecystic fluid reflecting acute inflammation. Multiple calculi were noted to be present within the CBD and gall bladder, resulting in dilation of CBD (15.8mm). The patient had ERCP with sphincterotomy and retrieval of multiple stones by balloon trawl. He was discharged the following day and is planned to undergo laparoscopic cholecystectomy as an elective procedure. His liver function test markedly improved at discharge bilirubin of 18 μmol/L and ALP of 364 IU/L. Conclusion This is an unusual case of painless jaundice with palpable gall bladder due to stones impacted in the CBD and not due to periampullary carcinoma, which is an exception to the Courvoisier's Law.