This document discusses Mirizzi syndrome, which is defined as extrinsic compression of the common hepatic duct by an impacted gallstone in the cystic duct or gallbladder. It presents the different classifications of Mirizzi syndrome, including the original 2 types described by McSherry in 1982 and the expanded 4 types described by Csendes in 1989. It details the clinical presentation, diagnostic imaging tools including ultrasound, CT, MRCP and ERCP, as well as the surgical approaches recommended for each type of Mirizzi syndrome.

1. Dr.Asif Mian Ansari
DNB Resident
Dept. of General surgery
Max super speciality Hospital,
Mohali, Punjab

2.  Extrinsic bile duct compression syndrome
 Pablo Luis Mirizzi (1948)  Hepatic duct syndrome
 Kehr (1905) & Ruge (1908)  partial CHD obstruction
secondary to impacted calculi & associated inflammation
 Compression of common hepatic duct  obstruction  liver
dysfunction

3.  Incidence :
 <1% in developed countries
 4.7 to 5.7% in developing countries
 Fourth to seventh decade of life
 Gall bladder cancer (>25%)
Updates in Mirizzi syndrome, Alan Isaac et al.
HepatoBiliary Surg Nutr 2017;6(3):170-178

4.  McSherry et al.(1982)  2 types
 Type I: partial or complete external obstruction of CHD
 Type II: cholecysto-choledochal fistula
 Csendes et al.(1989)  4 types
 Subclassified cholecysto-choledochal fistula
 In 2007, Csendes extended the classification which was
validated by Beltran

5. Type I
Type III
Type II
Type IV
TypeV

6. Type Incidence Mortality
I 10.5-52 % 0.6 %
II 23.2-41 % 4.0 %
III 44 8.0 %
IV 1-6 % 20 %
V 29 % 15-22 %
Updates in Mirizzi syndrome, Alan Isaac et al.
HepatoBiliary Surg Nutr 2017;6(3):170-178

7.  Fever
 Pain right upper abdomen
 Jaundice
 Nausea & vomiting
 Dark colored urine
 Patient may present as a case of acute cholecystitis, acute
cholangitis or acute pancreatitis

8. Gallbladder Atrophy—anomalous communication with: bile duct,
stomach, duodenum, colon, another abdominal
viscera
Infundibulum
(Hartmann’s pouch)
Impacted gallstone
Bile duct External compression, gallstone eroded, distal,
normal caliber, normal thickness walls
Proximal, normal caliber, thick and inflamed walls
Cystic duct Abnormal high merger with common hepatic duct
Entrance to right hepatic duct
Congenital anatomical variations
Fistula cholecysto-choledochal fistula , cholecysto-enteric
fistula

9.  High bilirubin,ALP andTransaminases
 ElevatedCA 19-9 (>20000 inType II or more)

10.  Ultrasonography:
 Contracted GB
 Impacted stone
 IHBR Dilatation above obstruction
 Sensitivity 8.3 to 57 %
 Specificity 90.9 to 100 %

11.  Computed tomography scan:
 Malignancy can be ruled out
 Peri-ductal inflammation can be
misinterpreted as Ca
 40-45 % sensitive
*Mirizzi Syndrome: Our Experience with 27 Cases
in PUMC Hospital; Xie-qun Xu,Chin Med Sci JVol. 28, No. 3
September 2013

12.  ERCP
 Detailed anatomy of syndrome
 Allows intervention (biopsy/removal of
calclui/stenting)
 Complications
*Mirizzi Syndrome: Our Experience with 27 Cases
in PUMC Hospital; Xie-qun Xu,Chin Med Sci JVol. 28, No. 3
September 2013
METHOD OF CHOICE

13.  MRCP
 Degree of obstruction
 Other causes of obstruction
 Non invasive
 Sometimes unable to diagnose fistula
 Sen – 77.8 to 100 %
 Sp – 93.5 %

14.  Intraoperative diagnosis
 Most common
 Contracted gall bladder with distorted anatomy
 Impacted stones in neck
 Obliterated calot’s

15. TYPE I Cholecystectomy with cholangiography
TYPE II (I) Subtotal cholecystectomy; (II) stone extraction, suture of bile duct and catheterization inT; (III)
Roux-en-Y hepaticojejunostomy; (IV) cholecysto-choledocho-duodenostomy; (V) cholecysto-
choledocho-jejunostomy
TYPE III (I) Subtotal cholecystectomy; (II) stone extraction, suture of bile duct and catheterization inT; (III)
Roux-en-Y hepaticojejunostomy; (IV) choledochoplasty
TYPE IV (I) Subtotal cholecystectomy; (II) bilioenteric to the duodenum anastomosis; (III) Roux-en-Y
hepaticojejunostomy
TYPEVa (I) Division and simple suture of biliary-enteric fistulas on the viscera involved; (II) total or subtotal
cholecystectomy according to the presence of a cholecystobiliary fistula
TYPEVb (I)Treating gallstone ileus; (II) in second intention total or subtotal cholecystectomy