It is characterized by extrinsic compression of the common hepatic duct by stones impacted in the cystic duct or the neck of the gallbladder.
The syndrome comprises a spectrum of anatomical alterations, where the most significant anomaly is the formation of a biliary-biliary fistula.
The gallbladder comprises the fundus, body, infundibulum, and neck. The body extends from the bottom towards the conical portion or neck.
The neck generally forms a smooth curve; the convexity includes the infundibulum or Hartmann’s pouch.
The gallbladder is connected in your neck to the cystic duct that empties into the common bile duct.
Large gallstones can impact the cystic duct or Hartmann’s pouch.
These stones can obstruct the common hepatic duct by mechanical obstruction of the hepatic duct due to the proximity of the cystic duct and the common hepatic duct and secondary inflammation with frequent episodes of cholangitis.
In rare cases, chronic inflammation can lead to necrosis of the bile duct wall and erosion of the anterior or lateral wall of the common bile duct by impacted stones leading to cholecystohepatic fistula or cholecystochedoloedol.
Mirizzi Syndrome is rare and challenging to manage the clinical entity. However, recent advances in technology have provided surgeons with new options for more effective diagnosis and treatment of this condition.
Kehr and Ruge were the first to describe this condition in the early 1900s, although the term ‘Mirizzi Syndrome’ was not adopted until after Mirizzi’s work in 1948.
This syndrome is a rare complication of chronic gallstone disease.
Physiopathologically, this condition involves extrinsic compression of the bile duct by pressure applied indirectly by an impacted stone in the infundibulum or neck of the gallbladder.
The resulting chronic inflammation and ulceration form varying degrees of cholecystobiliary fistula; in addition, cholecystoiderial fistula can also occur.
Causes of Mirizzi syndrome
This syndrome is caused by extrinsic compression of an impacted stone in the cystic duct or Hartmann’s bursa of the gallbladder.
Symptoms of Mirizzi syndrome
The clinical presentation of Mirizzi syndrome varies from asymptomatic to non-specific, with obstructive jaundice and elevated liver enzymes being the most common, abdominal pain in the right upper quadrant, and constitutional symptoms such as fever, nausea, vomiting, diarrhea, and constipation.
Although rare, Mirizzi syndrome can also present with gallstone ileus.
The nature of these presentations often causes this condition to be mistaken for a biliary tract neoplasm, and therefore misdiagnosis is common.
Diagnosis of Mirizzi syndrome
Preoperative diagnosis of Mirizzi syndrome and careful surgical planning is of utmost importance.
The most widely used diagnostic modalities are ultrasound, computed tomography, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography.
Endoscopic retrograde cholangiopancreatography is an invasive procedure that is useful to confirm the presence of Mirizzi syndrome with or without cholecystobiliary or cholecystoester fistulas and for therapeutic means that allow stone removal stenting, and other procedures.
An accurate preoperative diagnosis facilitates safe and effective surgical therapy. However, such a diagnosis is often overlooked before the operation, although more advanced disease cases are easier to detect before surgery.
Mirizzi syndrome treatment
The treatment of Mirizzi syndrome is surgical. Mirizzi syndrome is essential to surgeons because preoperative diagnosis is not always possible. Surgical treatment of this condition is associated with a significantly increased risk of bile duct injury.
Open cholecystectomy has been the standard treatment; however, laparoscopy has challenged this approach.
The importance and the ultimate goal of all classification systems for Mirizzi syndrome are to allow the surgeon to tailor the surgical approach to the individual case.
External compression of the bile duct. Open cholecystectomy, open subtotal cholecystectomy, laparoscopic cholecystectomy, and laparoscopic subtotal cholecystectomy are recommended as a treatment.
Cholecystobiliary fistula with a bile duct diameter less than 50%. Open cholecystectomy and open subtotal cholecystectomy are recommended as treatments.
Cholecystobiliary fistula with a bile duct diameter greater than 50%. Open subtotal cholecystectomy and biliary-enteric diversion from side to side to the duodenum en-Y-de-Roux to the jejunum are recommended as a treatment.
Cholecystobiliary fistula and cholecysto-enteric fistula without gallstone ileus. Simple closure of the fistula and treatment of the gallbladder are recommended as treatment depending on the presence of type I, type IIa, or type IIb Mirizzi.
Cholecystobiliary fistula and cholecysto-enteric fistula with gallstone ileus. It is recommended to treat gallstone ileus and deferred treatment for the gallbladder depending on the presence of type I, type IIa or type IIb Mirizzi.
Association with gallbladder cancer
Mirizzi syndrome has been associated with gallbladder cancer. It has been hypothesized that recurrent inflammation and biliary stasis may predispose to both conditions.