Biliary Tract: Mirizzi Syndrome

Mirizzi Syndrome

Definition

  • Common Hepatic Duct Obstruction Due to External Compression

Causes

  • Mechanical Obstruction from Stone in Gallbladder Infundibulum (Most Common Cause)
  • Secondary Inflammation of Common Hepatic Duct from Extension of Gallbladder/Cystic Duct

Presentation

  • Symptoms:
    • RUQ Pain
    • Fever
    • Jaundice
  • Labs:
    • Leukocytosis
    • Hyperbilirubinemia
    • Elevated LFT’s
  • Higher Risk of Gallbladder Cancer (5.3-28%)
    • Higher in Types II-IV

Classification

  • Type I: External Compression from Stone Impaction
  • Type II: Cholecystobiliary Fistula < 1/3 CBD Circumference
  • Type III: Cholecystobiliary Fistula 1/3-2/3 CBD Circumference
  • Type IV: Cholecystobiliary Fistula with Complete Destruction of CBD Wall
  • Type V: Type I-IV with Cholecystoenteric Fistula
    • Va: Without Gallstone Ileus
    • Vb: With Gallstone Ileus

Diagnosis

  • MRCP or ERCP are Preferred
  • US or CT May Be Considered

Treatment

  • Primary Treatment: Cholecystectomy (Partial Resection is Reasonable Depending on the Case)
    • Type I-II Can Be Done Laparoscopically
    • Type III-IV Should Be Done Open
  • Cholecystobiliary Fistula Management:
    • Type II – Primary Closure (Over a T-Tube)
    • Type III – Primary Closure vs Choledochojejunostomy
    • Type IV – Choledochojejunostomy
  • Cholecystoenteric Fistula:

Gallbladder (Dashed Arrow) Causing External Compression on the CHD (Solid Arrow), Cystic Duct (Arrowhead) 1

Mirizzi Classification 2

References

  1. Tuncer AA, Yilmaz S, Yavuz M, Çetinkurşun S. Minimally Invasive Treatment of Mirizzi Syndrome, a Rare Cause of Cholestasis in Childhood. Case Rep Pediatr. 2016;2016:8940570. (License: CC BY-4.0)
  2. Lacerda Pde S, Ruiz MR, Melo A, Guimarães LS, Silva-Junior RA, Nakajima GS. Mirizzi syndrome: a surgical challenge. Arq Bras Cir Dig. 2014 Jul-Sep;27(3):226-7. (License: CC BY-NC-4.0)