Mirizzi’s Syndrome

  • – Common Hepatic duct obstruction due to compression by a gall stone in the cystic duct
  • – It occurs in 1% of patients who undergo cholecystectomy
  • When to suspect Mirizzi’s syndrome?
  •                       During a difficult cholecystectomy

Types: 2 types

Type1:

  • – Hepatic duct is compressed by a large stone impacted in the cystic duct or Hartmann’s pouch
  • – Associated inflammation contributes to obstruction of the extrahepatic bile duct due to stricture formation

TypeII:

  • – Calculus that has eroded into the CHD to produce a cholecysto-choledochal fistula
  • Type II is again divided into II,III,IV types to guide surgical treatment which is called Csendes classification
  • Type II: <1/3rd of the bile duct is involved
  • Type III: Upto 2/3rd of the bile duct is involved
  • Type IV: >2/3rd of the bile duct is involved

Figure: Csendes classification of Mirizzi’s syndrome

 

Symptoms: Repeated bouts of pain, fever, and jaundice
Investigations:
          USG:
– Gall stone with contracted GB
– Moderate intrahepatic bile duct dilation
– Normal extrahepatic bile duct
        MRCP:  Same as USG

 

  •       Treatment:
          For Type I:
    – Cholecystectomy with or without bile duct exploration
    -In severe inflammation where the identification of anatomy is difficult, partial cholecystectomy with post-operative sphincterotomy is preferable
    For Type II, III:
  •                         – Partial cholecystectomy, stone removal, choledochoplasty
    For Type IV:
  •                          – Roux-en-y hepaticojejunostomy

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