Biliary Tract: 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:
  • Type Va – Single Surgery with Primary Repair
  • Type Vb – One-Stage vs Two-Stage Procedure
    • *See Biliary Tract: Gallstone Ileus