• The stone ulcerating through into the CBD • Mirizzi's syndrome is a condition characterized by stricture of the common hepatic duct. • Mirizzi's syndrome may be mistaken for pancreatic cancer or cholangiocarcinoma

P. L. Mirizzi
• In 1948, P. L. Mirizzi described an unusual presentation of gallstones which, when lodged in either the cystic duct or the Hartmann pouch of the gallbladder, externally compressed the common hepatic duct (CHD), causing symptoms of obstructive jaundice (Mirizzi, 1948).

• Impaction of a large gallstone (or multiple small gallstones) in the Hartmann pouch or cystic duct results in the Mirizzi syndrome in 2 ways: (1) Chronic and/or acute inflammatory changes lead to contraction of the gallbladder, which then fuses with and causes secondary stenosis of the CHD, or (2) large impacted stones lead to cholecystocholedochal fistula formation secondary to direct pressure necrosis of the adjacent duct walls. Increasingly, these phenomena are seen not as distinct and separate steps but as part of a continuum (Pemberton, 1997; Hazzan, 1999

• In 1982, McSherry et al proposed a 2stage classification based on the results of endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). Type I is simple external compression of the CHD, whereas type II involves the presence of a cholecystocholedochal fistula

• In the US: Mirizzi syndrome occurs in approximately 0.7-1.4% of all patients undergoing cholecystectomy and in 0.1% of all patients with gallstone disease (Pemberton, 1997; Hazzan, 1999).

• : Preinterventional diagnosis of this rare condition is critical to the patient's prognosis. Chronic inflammation that leads to fibrosis, scarring, edema, and fistula formation can wreak havoc on adjacent biliary structures and cause serious surgical consequences if unnoticed. Therefore, every patient in whom this abnormality is suspected (at initial ultrasonography or CT) must undergo anatomic evaluation with cholangiography prior to surgical intervention. • Extensive adhesions may make visualization of the biliary anatomy exceptionally difficult, especially within the hepatoduodenal ligament. Consequently, the CBD may be mistaken for the cystic duct, and ligation or permanent injury may occur during surgery (Becker, 1984). Postoperative bile leakage may occur if a fistula is not recognized; rarely, this may result in bile peritonitis

: the cystic duct is densely adherent to the CBD causing necrosis and fistulla between cystic duct,GB and CBD

What Causes Mirizzi's syndrome?
• Mirizzi's syndrome is caused by chronic cholecystitis and large gallstones resulting in constriction of the common bile duct. cholecystitis is an inflammation of the gallbladder that causes severe abdominal pain. • In some cases, the gallstone erodes into the common hepatic duct and produces a cholecystocholedochal fistula.

• • • • • • •

cholecystitis fever right upper quadrant pain recurrent cholangitis jaundice elevated bilirubin pancreatitis

Symptoms of Mirizzi's syndrome?


• : Ultrasonographic findings include (1) an impacted calculus in the Hartmann pouch or the cystic duct, (2) dilatation of the CHD above the level of the impacted stone, (3) narrowing of the CHD at the level of impaction, and (4) normal caliber of the CBD below the impaction

Can Mirizzi's Syndrome be Treated?
• Yes. Common treatments include removal of the gallbladder and reconstruction of the common bile duct and the hepatic duct.

• Mirizzi syndrome types II-IV (ie, fistula present) require more complex interventions. Type II defects are generally treated successfully with either cholecystectomy and closure around a ttube or partial cholecystectomy with in situ t-tube placement (Pemberton, 1997).

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