University of Louisville School of Medicine Louisville, KY, United States
Evan Winrich, MD, Apaar Dadlani, MBBS, Ashutosh Barve, MD, PhD, Tracy Vanmeter, MD University of Louisville School of Medicine, Louisville, KY
Introduction: Mirizzi syndrome refers to obstruction of the common hepatic duct (CHD) secondary to impacted biliary stones in the cystic duct or infundibulum of the gallbladder. We explore the case of a 54-year-old female with a possible malignant lesion likely mimicking Mirizzi syndrome.
Case Description/Methods: A 54-year-old female with history of hypertension presented with back pain radiating to the right upper quadrant (RUQ), with RUQ ultrasound showing CHD dilation. MRCP revealed cholelithiasis, evidence of contained gallbladder rupture with adjacent fluid collection, and a dilated cystic duct compressing the CHD consistent with Mirizzi syndrome. Numerous hyperintense liver lesions were also present. ERCP was performed with sphincterotomy and biliary stent placement. Liver biopsy showed poorly differentiated adenocarcinoma with possible biliary origin. Inpatient cholecystectomy was deferred given the presence of cancer. Her cancer was Her2/neu positive, and she was started on trastuzumab. MRCP obtained after 3 months of chemotherapy showed a non-dilated cystic duct, and ERCP for stent removal did not reveal any cholecystobiliary fistula.
Discussion: Traditionally, Mirizzi syndrome has been described as a result of a large biliary stone impacted either in the cystic duct or neck of the gallbladder. However, as seen in our case, it may be possible for a malignant lesion to mimic the clinical presentation of Mirizzi syndrome. Long-standing cholelithiasis has been found to play a causative role in both Mirizzi syndrome and the development of gallbladder cancer. Prior studies have shown that 5.3-28% of patients with Mirizzi syndrome have concurrent gallbladder cancer. Definitive diagnosis of gallbladder cancer can be achieved in the setting of suspected Mirizzi syndrome if surgical removal of the gallbladder is performed and a frozen section biopsy of the specimen is taken. Therefore, it is reasonable to suggest these frozen section biopsies in patients undergoing cholecystectomy for Mirizzi syndrome in order to rule out gallbladder cancer and guide further treatment. In our patient, this biopsy could not be obtained. However, the absence of a dilated cystic duct at three months following chemotherapy led to the suspicion that the original compression of the CHD was caused by an underlying cancer mimicking Mirizzi syndrome, rather than a stone.
Disclosures: Evan Winrich indicated no relevant financial relationships. Apaar Dadlani indicated no relevant financial relationships. Ashutosh Barve indicated no relevant financial relationships. Tracy Vanmeter indicated no relevant financial relationships.
Evan Winrich, MD, Apaar Dadlani, MBBS, Ashutosh Barve, MD, PhD, Tracy Vanmeter, MD. P1161 - Biliary Malignancy Mimicking Mirizzi Syndrome, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.