John H. Samies, DO1, Ruchit N. Shah, DO2, Marika Bergenstock, DO3, Bradley Confer, DO3, Harshit S. Khara, MD, FACG3; 1Geisinger Health System, Danville, PA; 2Geisinger Commonwealth School of Medicine, Danville, PA; 3Geisinger Medical Center, Danville, PA
Introduction: Mirizzi syndrome is a rare complication of cholelithiasis. Early recognition is necessary to prevent complications, including cholecystocholedochal or cholecystohepatic fistula formation, or surgical injury to the common bile duct during cholecystectomy. We report a case of Mirizzi syndrome that presented as abdominal pain secondary to acute calculous cholecystitis, masquerading as a malignant biliary obstruction on initial imaging.
Methods: A 56-year-old male presented with new onset abdominal pain, weakness, and progressive fatigue. His past medical history was pertinent for atrial fibrillation and systolic heart failure. Patient was afebrile, but hypotensive to 95/54 mmHg, with right upper quadrant abdominal tenderness and a palpable gallbladder on physical examination. He had a leukocytosis of 30 k/uL (ref: 4.0-10.8 k/uL) and mildly elevated liver enzymes. Abdominal ultrasound demonstrated a distended gallbladder, with common bile duct dilation of 10mm, and a suspicious 2.4 cm nodular area in the head of the pancreas, raising the concern for a malignant biliary obstruction. CT scan showed a distended gallbladder measuring 9.3 cm, with pericholecystic fat stranding, and findings indeterminate for a biliary stricture. Subsequent endoscopic ultrasound (EUS) revealed several gallstones measuring 20mm within the gallbladder, but no abnormality within the pancreas. The enlarged gallbladder caused extrinsic compression of the common hepatic duct, prompting ERCP for stent placement and biliary decompression prior to surgery. Patient subsequently underwent open cholecystectomy for the treatment of type 1 Mirizzi syndrome complicated by acute cholecystitis. He made a complete recovery after surgical intervention and antibiotic therapy. Discussion: Mirizzi syndrome is a rare complication of gallstone disease which can mimic a malignant biliary obstruction, thus early recognition is crucial. EUS and ERCP should be considered as diagnostic ad therapeutic modalities in these patients, and to help prevent bile duct injury during subsequent surgical intervention.
CT imaging showing gallbladder measuring 9.3 cm in diameter (arrow) with pericholecystic fat stranding.
EUS demonstrating a markedly enlarged gallbladder (arrow) with numerous gallstones
ERCP with stent placement for biliary decompression of the common hepatic duct stenosis.
Disclosures: John Samies indicated no relevant financial relationships. Ruchit Shah indicated no relevant financial relationships. Marika Bergenstock indicated no relevant financial relationships. Bradley Confer: Boston Scientific – Consultant. Merit Medical – Consultant. Harshit Khara indicated no relevant financial relationships.