mirizzi

1. MIRIZZI SYNDROME
Dr. Hiwa Omer Ahmed
ASSISTANT PROFESSOR IN
SURGERY

2. MIRIZZI SYNDROME
• 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

3. 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).

4. Pathophysiology:
• 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

5. • In 1982, McSherry et al proposed a 2-
stage 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

6. Frequency:
• 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).

7. Mortality/Morbidity
• : 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

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

9. 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.

10. Symptoms of Mirizzi's
syndrome?
• cholecystitis
• fever
• right upper quadrant pain recurrent
• cholangitis
• jaundice
• elevated bilirubin
• pancreatitis

14. cholangiogram

15. Findings
• : 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

16. 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.

17. Rx
• 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 t-
tube or partial cholecystectomy with in situ
t-tube placement (Pemberton, 1997).

18. Our patient