Makindo Medical Notes

Related Topics: | Gallstones | Jaundice | Cholecystectomy | Cholangitis

Mirizzi Syndrome is a rare complication of gallstones where a gallstone becomes lodged in the cystic duct or gallbladder neck, causing compression and possible obstruction of the common bile duct (CBD).

About Mirizzi Syndrome

• Rare cause of obstructive jaundice due to gallstone impaction.

Etiology

• Gallstone Impaction: A gallstone gets stuck in the cystic duct or the neck of the gallbladder, obstructing bile flow.
• Bile Duct Compression: The impacted stone causes either direct or indirect compression on the common bile duct, leading to obstruction.
• Chronic Inflammation: Long-standing inflammation may exacerbate bile duct compression and lead to further complications like fistulas.

Clinical Presentation

• Jaundice: Yellowing of the skin and eyes from elevated bilirubin levels.
• Right Upper Quadrant Pain: Persistent severe pain in the upper right abdomen.
• Fever and Chills: Signs of potential cholangitis.
• Nausea and Vomiting: Due to biliary obstruction.
• Pruritus: Itching from accumulated bile salts under the skin.
• Dark Urine and Pale Stools: From blocked bile excretion.

Classification of Mirizzi Syndrome

• Type I: No fistula present.
• Type IA: Cystic duct is visible.
• Type IB: Cystic duct obliterated.
• Type II: Small fistula involving less than 33% of the CBD diameter.
• Type III: Fistula involving 33-66% of the CBD diameter.
• Type IV: Large fistula involving more than 66% of the CBD diameter.

Investigations

• Liver Function Tests (LFTs): Elevated bilirubin and alkaline phosphatase.
• Ultrasound: First-line imaging to detect gallstones and biliary dilation.
• Magnetic Resonance Cholangiopancreatography (MRCP): Provides detailed images of the bile ducts, identifying obstruction sites and any associated fistulas.
• Endoscopic Retrograde Cholangiopancreatography (ERCP): Allows both diagnosis and therapeutic interventions like stone removal or stent placement.
• CT Scan: Useful for assessing inflammation extent and complications.

Management

• Cholecystectomy: Surgical removal of the gallbladder to alleviate obstruction and prevent recurrence.
• ERCP: Effective for removing the impacted stone or placing a stent to temporarily relieve obstruction.
• Surgical Bile Duct Repair: Necessary for managing fistulas; options range from simple repairs to complex reconstructions like Roux-en-Y hepaticojejunostomy.
• Antibiotics: Administered if cholangitis is present to prevent infection spread prior to surgery.
• Note: Delayed treatment can lead to serious complications such as chronic cholangitis, biliary cirrhosis, or even biliary tract cancer.