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Management:

  • Surgery is considered the mainstay of treatment. However, successful endoscopic therapy and electrohydraulic lithotripsy have been reported. (Answer choices B, and possibly C and/or D in some cases).
  • In this case, exploratory laparotomy and cholecystectomy with Roux-N-Y choledochojejunostomy was performed. Operative findings were consistent with Mirizzi syndrome. Impacted stones had eroded completely into the common hepatic duct.

Discussion:

  • MRI FINDINGS IN THIS CASE: Massively dilated intra-hepatic and extra-hepatic biliary ducts with multiple large gallstones in a contracted gallbladder. Consistent with Mirizzi syndrome.
  • DEFINITION: Mirizzi syndrome refers to common hepatic duct obstruction caused by extrinsic compression from a gallstone impacted in the cystic duct or gallbladder neck. Initially described by P.L. Mirizzi in 1948.
  • CLASSIFICATION: Several classification schemes have been proposed. Initial classification included: Type I, with compression of the common hepatic duct by a stone impacted in the cystic duct or Hartmann's pouch without fistula; and Type II, with erosion of the calculus from the cystic duct into the common hepatic duct, producing a cholecystocholedochal fistula.
    • Alternatively, can be classified into four types (Csende's classification):
      • Type I: external compression of the common bile duct.
      • Type II: a cholecystobiliary fistula is present with erosion of less than one-third of the circumference of the bile duct.
      • Type III: the fistula involves up to two-thirds of the duct circumference.
      • Type IV: there is complete destruction of the bile duct.
  • IMAGING: Ultrasonography is often a first-line study. CT can be helpful in ascertaining if malignancy is present. Cholangiography is necessary to establish the correct diagnosis and delineate hepatic duct anatomy (ERCP, MRCP).
  • TREATMENT: Surgery is the mainstay of treatment for Mirizzi syndrome. Laparoscopic surgery as the primary treatment remains controversial, given the increased risk of biliary injury with Mirizzi syndrome, although it appears to be feasible, especially with Type I anatomy. Endoscopic treatment with or without electrohydraulic lithotripsy can be utilized as a temporizing measure prior to surgery and can be definitive treatment for unsuitable surgery candidates.

References

Baer HU, Matthews JB, Schweizer WP, et al: Management of the Mirizzi syndrome and the surgical implications of cholecystcholedochal fistula. Br J Surg 1990 Jul; 77(7): 743-5

Csendes A, Diaz JC, Burdiles P, et al: Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg 1989 Nov; 76(11): 1139-43

England RE, Martin DF, Endoscopic management of Mirizzi's syndrome. Gut 1997; 40: 272-276

www.emedicine.com. Mirizzi syndrome. Ross et al.

www.uptodate.com. Mirizzi syndrome. Umashanker and Chopra.


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