A 68-year-old man presents with progressive painless jaundice, weight loss and pruritus over one month. On examination he is deeply jaundiced and a non-tender, globular mass is palpable in the right upper quadrant. Applying Courvoisier's law, what does the palpable gallbladder in this jaundiced patient suggest?

Answer: C. Gallstones are an unlikely cause and malignancy should be suspected

Courvoisier's law and painless obstructive jaundice

Courvoisier's law states that in the presence of jaundice, a palpable, non-tender gallbladder is unlikely to be due to stones. The reasoning is that chronic gallstone disease produces a fibrosed, shrunken gallbladder that cannot distend, whereas a gallbladder distended by back-pressure usually reflects a more distal malignant obstruction (classically carcinoma of the head of the pancreas or a periampullary tumour).

Why this points to malignancy

• Painless, progressive jaundice with weight loss in an elderly patient is the classic picture of malignant biliary obstruction.
• A distensible (previously normal) gallbladder enlarges as pressure rises behind a slowly obstructing tumour.

Benign vs malignant causes of obstructive jaundice

Painful vs painless

• Stone disease: often painful, with biliary colic and intermittent/fluctuating jaundice.
• Malignancy: typically painless and progressive, with weight loss preceding (pancreatic/cholangio) or following (periampullary) the jaundice.