A Case of Mirizzi Syndrome with Erosion into the Common Hepatic Duct
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A Case of Mirizzi Syndrome with Erosion into the Common Hepatic Duct Jenny Zhang 1 & Pranith Perera 2 & Rachel Beard 1 Received: 12 October 2020 / Accepted: 31 October 2020 # 2020 The Society for Surgery of the Alimentary Tract
An 82-year-old woman was initially referred to our hospital after workup for anemia by her primary care physician showed abnormal liver function tests (total bilirubin 3.8) and leukocytosis (white blood cell 16.3 K), concerning for acute cholecystitis with extrinsic compression of gallbladder. She was treated with antibiotics and underwent endoscopic retrograde cholangiopancreatography (ERCP) with plastic stent placement. Initial imaging raised concern for possible malignancy and she was discharged with plans to complete a staging workup and follow-up outpatient. She subsequently declined further follow-up with both her gastroenterologist and surgeon, and ultimately re-presented to the hospital five months later in shock with hypotension and total bilirubin 3.5. She was diagnosed with cholangitis complicated by a right hepatic abscess and underwent emergent ERCP (Fig. 1). It was noted that her prior plastic stent was clogged, there was debris in the duct, and there was a large radio-opaque object consistent with gallstone with significant resistance with the sphinctertome suggestive of Mirizzi syndrome. Her plastic stent was replaced and her hepatic abscess was drained. Once she was clinically stable, she consented for an open cholecystectomy. Intraoperatively a large gallstone was found to be eroding through the back of the gallbladder and into the liver, with erosion into the intraheptic common hepatic duct. When the gallstone was removed, the plastic stent from the ERCP was clearly visible through the defect in the wall of the duct (Fig. 2). A side* Jenny Zhang [email protected] 1
Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 4, Providence, RI 02903, USA
2
Department of Gastroenterology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
to-side Roux-en-Y hepaticojejunostomy was performed. Pathology from her surgical specimen showed active and chronic cholecystitis. Her hospital course was complicated by respiratory failure requiring BiPaP, pleural effusion requiring thoracentesis, and difficulty with oral intake requiring percutaneous endoscopic gastrostomy placement. She was ultimately discharged to skilled nursing facility on POD 19. Mirizzi syndrome, a rare disorder with an incidence of 0.7 to 1.4%, is characterized by obstruction of the common bile duct or common hepatic duct due to external compression by an impacted gallstone.1 According to the Csendes classification, there are five main categories. Type I involves external compression of the bile duct by an impacted stone in the cystic duct or the gallbladder infundibulum. Type II to type IV is characterized by the presence of a cholecystobiliary fistula and extent of erosion into the bile duct. Typ
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