What is Mirizzi's syndrome?

From the Guidelines

Mirizzi's syndrome is a rare complication of gallstone disease where a stone becomes impacted in the cystic duct or neck of the gallbladder, causing compression of the common hepatic duct, and it is crucial to recognize and treat it promptly to prevent serious complications, as highlighted in the 2020 World Society of Emergency Surgery guidelines 1.

Definition and Classification

Mirizzi's syndrome is characterized by the compression of the common hepatic duct, which can lead to obstruction of bile flow, resulting in jaundice, abdominal pain, and potentially cholangitis (bile duct infection) 1. The condition is classified into different types based on the extent of bile duct involvement, ranging from simple external compression (Type I) to complete erosion into the bile duct creating a cholecystobiliary fistula (Types II-IV) 1.

Diagnosis and Treatment

Diagnosis typically involves imaging studies such as ultrasound, CT scan, MRCP (Magnetic Resonance Cholangiopancreatography), or ERCP (Endoscopic Retrograde Cholangiopancreatography) 1. Treatment is primarily surgical, with the approach depending on the type of Mirizzi's syndrome. Type I is usually managed with cholecystectomy (gallbladder removal), while more advanced types may require more complex biliary reconstruction procedures 1.

Importance of Early Recognition

Early recognition of Mirizzi's syndrome is essential to prevent serious complications, including biliary cirrhosis and liver damage, as emphasized in the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy 1. A thorough preoperative work-up is mandatory to detect at-risk conditions, such as Mirizzi syndrome, and to discuss the risks and benefits of the procedure 1.

Key Points

• Mirizzi's syndrome is a rare complication of gallstone disease that requires prompt recognition and treatment.
• The condition is classified into different types based on the extent of bile duct involvement.
• Diagnosis involves imaging studies, and treatment is primarily surgical.
• Early recognition is crucial to prevent serious complications, including biliary cirrhosis and liver damage.
• A thorough preoperative work-up is essential to detect at-risk conditions, such as Mirizzi syndrome, and to discuss the risks and benefits of the procedure 1.

From the Research

Definition of Mirrizi's Syndrome

• Mirrizi's syndrome is a rare complication of chronic gallstones, characterized by a set of symptoms resulting from obstruction of the common hepatic or common bile duct (CBD) 2, 3.
• The obstruction is typically caused by extrinsic compression from an impacted gallstone in the gallbladder neck or cystic duct, or by inflammatory changes secondary to chronic gallstone cholecystitis 2, 4.

Clinical Presentation

• The most common presenting symptoms of Mirrizi's syndrome are abdominal pain and jaundice 2, 4, 5.
• Other symptoms may include nausea and vomiting 5.
• The syndrome can be classified into different types, with type I being the most common, characterized by extrinsic compression of the common hepatic duct by a stone impacted in the cystic duct or gallbladder neck 4, 5.

Diagnosis

• Preoperative diagnosis of Mirrizi's syndrome can be challenging, but it is essential to avoid bilio-vascular injuries and misdiagnosed malignancy 3, 5.
• Imaging modalities such as ultrasonography, CT, and magnetic resonance cholangiopancreatography (MRCP) can be used to diagnose Mirrizi's syndrome 6.
• Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for diagnosing Mirrizi's syndrome, as it can delineate the cause, level, and extent of biliary obstruction, as well as ductal abnormalities 6.

Treatment

• Treatment of Mirrizi's syndrome is primarily surgical, with open surgery being the current standard of care 4, 6.
• Laparoscopic management may be possible in selected cases, but it is contraindicated in many patients due to the increased risk of morbidity and mortality 4, 5.
• Endoscopic treatment may serve as an alternative in patients who are poor surgical candidates, or as a temporizing measure to provide biliary drainage in preparation for elective surgery 6.