What is the relationship between gallstone ileus and Mirizzi syndrome?

From the Guidelines

Gallstone ileus and Mirizzi syndrome are two distinct complications of gallstone disease that require prompt diagnosis and treatment to prevent serious complications. Gallstone ileus occurs when a large gallstone erodes through the gallbladder wall into the intestine, causing a mechanical bowel obstruction. Patients typically present with abdominal pain, nausea, vomiting, and signs of bowel obstruction. Treatment requires urgent surgical intervention to remove the obstructing stone through an enterotomy, with definitive cholecystectomy potentially performed later. Mirizzi syndrome, on the other hand, develops when a gallstone becomes impacted in the cystic duct or neck of the gallbladder, causing compression and obstruction of the common hepatic duct. This presents with right upper quadrant pain, jaundice, and abnormal liver function tests. Management typically involves surgical intervention with cholecystectomy and careful dissection to avoid bile duct injury. In complex cases, partial cholecystectomy or biliary-enteric reconstruction may be necessary. Both conditions require prompt diagnosis with imaging studies such as CT scan or MRCP to guide appropriate treatment. Early surgical consultation is essential as these conditions can lead to serious complications including perforation, peritonitis, or biliary sepsis if not properly managed, as highlighted in the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy 1. It is also important to note that an exhaustive preoperative work-up prior to cholecystectomy is mandatory in order to detect at-risk conditions, such as Mirizzi syndrome, and discuss the risks/benefits ratio of the procedure 1. Key points to consider in the management of these conditions include:

• Prompt diagnosis with imaging studies
• Urgent surgical intervention for gallstone ileus
• Surgical intervention with cholecystectomy and careful dissection for Mirizzi syndrome
• Early surgical consultation to prevent serious complications
• Preoperative work-up to detect at-risk conditions and discuss the risks/benefits ratio of the procedure.

From the Research

Relationship between Gallstone Ileus and Mirizzi Syndrome

• Gallstone ileus and Mirizzi syndrome are both complications of gallstone disease, as discussed in 2.
• Mirizzi syndrome is characterized by the obstruction of the proximal bile duct due to extrinsic compression by an impacted stone in the gallbladder neck or local inflammatory changes, as described in 3.
• Gallstone ileus, on the other hand, refers to small bowel obstruction resulting from the impaction of one or more gallstones after they have migrated through a cholecystoenteric fistula, as mentioned in 2.
• Both conditions can present with similar symptoms, such as abdominal pain, nausea, and jaundice, making diagnosis challenging, as noted in 4 and 5.
• The diagnosis of Mirizzi syndrome can be achieved through various imaging modalities, including ultrasonography, CT, and magnetic resonance cholangiopancreatography (MRCP), as discussed in 4 and 3.
• Treatment for Mirizzi syndrome is primarily surgical, with open surgery being the current standard, as stated in 4 and 6.
• Gallstone ileus, as a complication of gallstone disease, may be related to Mirizzi syndrome in that both conditions involve the obstruction of the bile duct or small bowel by gallstones, as discussed in 2.

Diagnostic Challenges

• The diagnosis of Mirizzi syndrome and gallstone ileus can be difficult due to the similarity in symptoms and the rarity of these conditions, as mentioned in 2 and 5.
• Imaging modalities, such as ultrasonography, CT, and MRCP, can aid in the diagnosis of Mirizzi syndrome, but may not always be able to distinguish it from other gallbladder pathologies, as noted in 4 and 3.
• Endoscopic retrograde cholangiopancreatography (ERCP) is considered the gold standard for diagnosing Mirizzi syndrome, as stated in 4 and 6.

Treatment Options

• Treatment for Mirizzi syndrome is primarily surgical, with open surgery being the current standard, as stated in 4 and 6.
• Laparoscopic management may be possible in selected cases, but is not recommended for all patients, as noted in 3 and 6.
• Endoscopic treatment, such as biliary stent placement, may be an alternative for patients who are poor surgical candidates, as mentioned in 4 and 5.