Unusual Case of Mirizzi Syndrome Presenting as Painless Jaundice.

BACKGROUND Isolated painless jaundice is an uncommon presenting sign for Mirizzi syndrome, which is typically characterized by symptoms of acute or chronic cholecystitis. We report a rare case of Mirizzi syndrome with an acute onset of painless obstructive jaundice. CASE REPORT A 60-year-old man with an unremarkable prior medical history presented with 1 week of jaundice, dark urine, and acholic stools. His laboratory studies revealed a pattern of cholestasis with marked direct hyperbilirubinemia. Ultrasound and magnetic resonance imaging studies demonstrated intrahepatic ductal dilation and cholelithiasis, including a stone within the cystic duct. Endoscopic retrograde cholangiopancreatography with SpyGlass cholangioscopy confirmed the diagnosis of Mirizzi syndrome. CONCLUSIONS An atypical presentation of Mirizzi syndrome should be suspected in the setting of biliary obstruction without pain. The differential diagnosis is broad and includes choledocholithiasis, ascending cholangitis, and hepatobiliary malignancy. Evaluation should include laboratory studies and biliary tract imaging. Noninvasive biliary tract imaging can help exclude malignancy and confirm ductal dilation but is not sensitive for Mirizzi syndrome. Endoscopic retrograde cholangiopancreatography can serve both diagnostic as well as therapeutic purposes via stone extraction and stent placement. SpyGlass cholangioscopy can also augment management in the form of Electrohydraulic lithotripsy. Although therapeutic biliary endoscopy can be very effective, cholecystectomy remains the definitive treatment for Mirizzi syndrome.

[Mirizzi syndrome management (in Russian only)]. / Lechenie sindroma Mirizzi.

AIM: To assess an effectiveness of complex preoperative diagnosis, conservative treatment, minimally invasive biliary decompression for Mirizzi syndrome and to analyze surgical outcomes depending on the effectiveness of minimally invasive biliary decompression. MATERIAL AND METHODS: There were 67 patients with Mirizzi syndrome aged 27-96 years (mean age -64.8 years). The diagnosis was established on the basis of complaints, objective data, laboratory survey, abdominal X-ray, ultrasound (US), endoscopic gastroduodenoscopy (EGDS), computed tomography (CT) and magnetic resonance imaging (MRI). Extrahepatic bile duct visualization in case of suspected biliodigestive fistula was achieved by using of percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography, cholecystocholangiography, intraoperative cholangiography. RESULTS: The analysis of the diagnosis and treatment of patients with Mirizzi syndrome and mechanical jaundice with and without symptoms of cholangitis was carried out. It should be noted that percutaneous transhepatic cholangiography and cholecystocholangiography with antegrade contrasting were able to confirm Mirizzi syndrome type 1 without complications. Retrograde cholangiopancreatography in patients with Mirizzi syndrome type 2 reduced the diagnostic value of contrast-enhancement with complications in every fifth patient. Percutaneous drainage for Mirizzi syndrome type 1 was effective in all patients. There was low effectiveness of medication for Mirizzi syndrome. Medication combined with antegrade biliary decompression was 7 times more effective than retrograde decompression. All patients underwent surgery. Mortality depended on surgical emergency and effectiveness of biliary decompression. So, emergency interventions were followed by mortality rate near 60% while there were no deaths after elective procedures. Overall mortality was 11.9%.

ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis.

Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.

An Elderly Woman with Abdominal Pain: Mirizzi Syndrome.

BACKGROUND Mirizzi syndrome is an uncommon but clinically important complication of gallbladder disease that occurs when there is extrinsic compression of the common hepatic duct from gallstones within the cystic duct or from within the gallbladder itself. Obstructive jaundice and cholangitis may ensue. In severe cases, bile duct erosion or gallbladder rupture occur. CASE REPORT A demented 80-year-old woman presented to the Emergency Department (ED) with fever and right upper-quadrant abdominal guarding and tenderness. Computed tomography of the abdomen revealed a markedly dilated and thickened gallbladder with hyperdensity in the region of the gallbladder neck. The mass effect of these gallstones caused central intrahepatic biliary ductal dilatation from extrinsic compression of the extrahepatic biliary duct, consistent with Mirizzi syndrome. Additionally, there were 2 areas of focal rupture of the gallbladder wall. General Surgery recommended non-operative management and temporizing the patient with a cholecystostomy tube. She remained in the hospital on IV antibiotics and discharged to follow-up as an outpatient with General Surgery. CONCLUSIONS Significant morbidity and mortality can be associated with the disease states of Mirizzi syndrome, and it is imperative for the ED physician to promptly recognize and treat such clinical entities. In general, treatment requires a multidisciplinary approach, using the history and physical examination to guide appropriate consultation with General Surgery, Gastroenterology, or Interventional Radiology. The prognosis of Mirizzi syndrome is related to the degree of concomitant complications. Aggressive treatment is appropriate for most patients, with surgical intervention being individualized based on the stage and severity of the disease.

Gallstone Disease: Cholecystitis, Mirizzi Syndrome, Bouveret Syndrome, Gallstone Ileus.

Gallstone disease is a leading cause of morbidity in the United States and usually requires surgical or endoscopic interventions for diagnosis and/or treatment. Although gallstone disease is classically associated with the inflammatory sequela of cholecystitis, gallstones can also contribute to other clinical presentations such as gallstone ileus, Mirizzi syndrome, and Bouveret syndrome. This article explores the common-and uncommon-causes of surgical pathology owing to gallstones with an emphasis on clinical identification, diagnostics, and management options.

Combination of electrohydraulic lithotripsy and laparoscopy for gallbladder access in type III Mirizzi syndrome.

INTRODUCTION: A 50-year-old Japanese man presented with obstructive jaundice. We performed endoscopic retrograde biliary drainage before biliary decompression. CT showed a thickened gallbladder wall with low-density areas and a 35-mm gallstone; the stone was impacted in the gallbladder neck and cystic duct. The patient was therefore diagnosed with Mirizzi syndrome (type II or III) and scheduled for laparoscopic treatment. We performed subtotal cholecystectomy and intraoperative choledochoscopy because we recognized a fistula between the gallbladder and common bile duct preoperatively. MATERIALS AND SURGICAL TECHNIQUE: We opened the ductus choledochus, and a choledochoscope was introduced under laparoscopic guidance. An electrohydraulic lithotripsy probe with irrigation was passed through the choledochoscope to extract the gallstone. DISCUSSION: This fragmentation technique is effective for impacted large stones observed in Mirizzi syndrome. Therefore, electrohydraulic lithotripsy with laparoscopy is effective in cases of difficult gallbladder access such as that that occurs in type II or III Mirizzi syndrome.

Manejo mini-invasivo de la litiasis coledociana / MINIMALLY INVASIVE SURGERY OF CHOLEDOCHOLITHIASIS

Choledocholithiasis is one of the more common benign disorders of the biliary tract with multiple features of presentation and several alternatives for its diagnosis and treatment. Our aim was to perform a based-evidence revision to propose a diagnostic and therapeutic algorithm. The raised values of gamma glutamiltranspeptidase, alkaline phosphatase and total bilirubin, are well predictors for a choledocholithiasis. The image evidence for a pre-operative detection with higher sensibility, specificity and better cost-effectiveness is the cholangioresonance. For its intraoperative detection, the cholangiography is the method most frequently used, though cholangioscopy is likewise useful. In the case of a post-operative suspicious, the cholangiography through the T tube is the gold standard. With regard to the treatment of the choledocholithiasis, the different stages are analyzed. depending if the detection was performed pre, intra or postoperatively. As a conclusion, the approach of the choledocholithiasis in one step seems to be better that to perform it in two steps, being the laparoscopic exploration for bile ducts stones more safety than the use of the intraoperative ERCP (endoscopic retrograde cholangiopancreatography) .The postoperative ERCP is not recommended excepting in very selected cases, and the biliodigestive derivations should be reserved only for the primary lithiasis of the common bile duc

Usefulness of single-operator cholangioscopy-guided laser lithotripsy in patients with Mirizzi syndrome and cystic duct stones: experience at a tertiary care center.

BACKGROUND AND AIMS: ERCP is an established technique for the management of bile duct stones. Large bile duct stones (>1.2 cm) require additional techniques such as mechanical lithotripsy and balloon sphincteroplasty for ductal clearance. The literature on endoscopic management of cystic duct stones (CDSs) and Mirizzi syndrome (MS) is limited. We report our experience with cholangioscopy-assisted extraction of CDSs and MS in patients in whom conventional endoscopic and surgical techniques failed. METHODS: Between August 2011 and August 2014, 50 patients (15 males) diagnosed with MS (n = 40) and CDSs (n = 10) were recruited for the study. MRCP was the preferred diagnostic modality to outline the biliary anatomy. ERCP was performed by using an Olympus TJF 160/180 duodenoscope (Olympus, Tokyo, Japan). Cholangioscopy was performed by using the Spyglass system (Boston Scientific, Marlborough, Mass). Holmium laser lithotripsy (LL) was performed when conventional stone extraction techniques failed. RESULTS: Cholangioscopy-guided LL was required in 34 of 50 patients (68%) with MS and CDSs. Stone extractions using conventional endoscopy techniques were successful in 8 patients and with surgery in another 8 patients, and these patients were excluded from the final statistical analysis. The mean stone size for MS was 21 mm (range 15-41 mm), and the CDS size was 8 mm (range 6-12 mm). Single-session ductal clearance could be achieved in 32 patients (94%). Adverse events were mild and included fever (2 patients), transient abdominal pain (2 patients), and self-limited pancreatitis (2 patients). CONCLUSIONS: Cholangioscopy-guided LL is a useful technique for extraction of CDSs and in MS with high single-session success rates. It is also a rescue technique in patients in whom surgical stone extraction failed.

Advances in the endoscopic management of common bile duct stones.

Extraction of common bile duct stones by endoscopic retrograde cholangiopancreatography generally involves biliary sphincterotomy, endoscopic papillary balloon dilation or a combination of both. Endoscopic papillary large-balloon dilation after sphincterotomy has increased the safety of large stone extraction. Cholangioscopically directed electrohydraulic and laser lithotripsy using single-operator mother-daughter systems or direct peroral cholangioscopy using ultraslim endoscopes are increasingly utilized for the management of refractory stones. In this Review, we focus on advances in endoscopic approaches and techniques, with a special emphasis on management strategies for 'difficult' common bile duct stones.

[Clinical questions of extremal processing of Mirizzi syndrome].

In this article two clinical cases of Mirizzi syndrome is presented. In the observation examined reactive processing of Mirizzi syndrome I with severe overall system reaction to endogenous infection. The data characterizing the current version of Mirizzi syndrome V b is considered in the second observation. Timely diagnosis of Mirizzi syndrome and determination of the most appropriate method of treatment can reduce the risk of intraoperative injury.

Double-cannulation and large papillary balloon dilation: key to successful endoscopic treatment of mirizzi syndrome in low insertion of cystic duct.

Mirizzi syndrome is a rare cause of benign biliary obstruction and is often predisposed by low insertion of the cystic duct on the common hepatic duct. Through a case series of three patients, we emphasize the importance of double cannulation (cystic duct and hepatic duct) followed by sphincterotomy and large balloon papillary dilatation for successful endoscopic stone clearance in such patients.