Thread by @DrArunKValsan

🔴🟠🟢 Hepatology Bedside Pearls

Curvoisier-Terrier Sign!

(Arun's Gastro Aphorism☺
It's unlikely that you have finished Gastro rotation and never heard of this!)

🟠What's in a name?
❌a.k.a Curvoisier's Law (well hey, there ain't any laws in medicine!)

✔Curvoisiers gallbladder ( A Verghese, Lancet 1986)

✔Curvoisiers Sign

✔✔Curvoisier-Terrier Sign ( personal preference!)

🟠 What exactly is it?
"In a patient with painless jaundice, a palpable gallbladder is unlikely due to stones"
Most likely malignancy

🟢History Buffs assemble here!
🔶Ludwig George Curvoisier(1843-1918)
✔ Sx from Basel, 🇨🇭
✔Trained under Czerny& Billroth
✔1st choledocholithotomy
✔Post Gastroenterostomy
✔Best works in non-medical !!
🔶Louis Felix Terrier(1837-1908)
✔Sx from 🇫🇷

🟠Original description
n=187; 87 stones, 100 others
70/87(80℅) - GB atrophic
92/100(92%) - GB distended.
Concluded that malignancy was more likely if GB distended

(The Pathology & Surgery of Biliary tract, 1890)

(JAMA, 1968)

🟠 Mechanistic explanation

✔Stones⏩irritate⏩c/c infl⏩fibrosis
✔Tumor⏩incr retrograde hydrostatic pre⏩GB distension

(Garcia J, Rev Esp Enferm Dig 2007)

🟠Scientific backing?
✔Malig➡higher ductal pre, jaundice duration vs stones
But both groups has similar GB pliability
(RS Chung, Dis dis Sci 1983)

🛑Why stones don't cause high ductal pre?? 💡💡💡
❌No one really knows for sure!
Probably due to
? Incomplete obstrn
? More dramatic clinical presentation⏩seek medical attention earlier??

(RS Chung, Dig dis Sci 1983)

🚫Exceptions to the "law"!
🔴Double impaction of stones( in CD & CBD)
🔴Pancr stone obstr Amp of Vater
🔴Oriental cholangiohepatitis
🔴 C/c and AIP
🔴Choledochal cyst
🔴Hilar CCA
🔴Periportal LNE
🔴Mirizzis synd
🔴Periamp Ca post CCx
🔴AIDS Cholangio

Exceptions can be thought of as
⛔ Malignancy without GB distension
➕Benign conditions with GB distension

(epomedicine.com)

🟠Is it still relevant?
✔Times of original description and advanced imaging in present day⏩ incomparable
✔Objective measurements of GB vol appears to validate Curvoisier sign!! (n=394)

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@threadreaderapp "unroll"

🟠 Stats
✔High specificity (83-90%)
❌Poor sensitivity (23-56%)
for malignant biliary obstruction

🤬How to mess up spectacularly:101

(World J Surg 2009)