Answer for BIR CoW 29 Sep 2024
Mirizzi syndrome with cholecystitis
Findings
Calculus noted in cystic duct at its insertion site into common hepatic duct causing compression over common hepatic duct with upstream dilatation of central and peripheral intrahepatic biliary radicles. Gall bladder appears distended with edematous and thickened wall ( Maximum thickness 4.5mm) with pericholecystic free fluid and fat stranding noted. Distal common bile duct and main pancreatic duct appears normal in caliber.
Discussion
Impression-Distended gall bladder with cystic duct calculus and pericholecystic inflammatory changes-Calculus cholecystitis. Cystic duct calculus at insertion site causing compression over common hepatic duct and bilateral intra hepatic biliary radicle dilatation-Type I Mirizzi syndrome. Discussion: Mirizzi syndrome – uncommon phenomenon that results from extrinsic compression of an extra hepatic biliary duct from one or more impacted calculi within the cystic duct or gallbladder. Clinical presentation Patients may present with recurrent episodes of jaundice and cholangitis. It can be associated with acute cholecystitis. Csendes classification: type I: extrinsic compression of the common hepatic duct (CHD) type Ia: by impacted gallstone in the gallbladder neck or cystic duct type Ib: if cystic duct is absent 7 type II: erosion of CHD wall and formation of cholecystocholedochal fistula (up to one-third CHD wall circumference is involved) type III: up to two-thirds of CHD wall circumference is involved in a cholecystocholedochal fistula type IV: entire CHD wall is involved in a cholecystocholedochal fistula type V: any of the above with cholecystoenteric fistula MRI findings: MRCP classically shows a large impacted gallstone in the gallbladder neck or cystic duct, or signs of inflamed gallbladder causing proximal dilatation of the extra and intrahepatic biliary tree, with distal gradual tapering of the extrahepatic biliary duct caliber to the site of obstruction. Complications: Prolonged biliary obstruction and inflammation may lead to: Cholecystobiliary fistula: leads to choledocholithiasis cholecystocutaneous fistula Gallstone ileus : if the stone passes into the small bowel through a cholecystoenteric fistula Secondary biliary cirrhosis Delayed onset biliary stricture
References:
Klekowski J, Piekarska A, Góral M, Kozula M, Chabowski M. The Current Approach to the Diagnosis and Classification of Mirizzi Syndrome. Diagnostics (Basel). 2021;11(9):1660. doi:10.3390/diagnostics11091660 - Pubmed Bellamlih H, Bouimetarhan L, En-Nouali H, Amil T, Chouaib N, Jidane S, Rafai M, Belkouch A, Belyamani L. [Mirizzi's syndrome: a rare cause of biliary tract obstruction: about a case and review of the literature]. Pan Afr Med J. 2017;27:45. - PMC - PubMed Jones M & Ferguson T. Mirizzi Syndrome. 2024. - Pubmed
Findings
Calculus noted in cystic duct at its insertion site into common hepatic duct causing compression over common hepatic duct with upstream dilatation of central and peripheral intrahepatic biliary radicles. Gall bladder appears distended with edematous and thickened wall ( Maximum thickness 4.5mm) with pericholecystic free fluid and fat stranding noted. Distal common bile duct and main pancreatic duct appears normal in caliber.
Discussion
Impression-Distended gall bladder with cystic duct calculus and pericholecystic inflammatory changes-Calculus cholecystitis. Cystic duct calculus at insertion site causing compression over common hepatic duct and bilateral intra hepatic biliary radicle dilatation-Type I Mirizzi syndrome. Discussion: Mirizzi syndrome – uncommon phenomenon that results from extrinsic compression of an extra hepatic biliary duct from one or more impacted calculi within the cystic duct or gallbladder. Clinical presentation Patients may present with recurrent episodes of jaundice and cholangitis. It can be associated with acute cholecystitis. Csendes classification: type I: extrinsic compression of the common hepatic duct (CHD) type Ia: by impacted gallstone in the gallbladder neck or cystic duct type Ib: if cystic duct is absent 7 type II: erosion of CHD wall and formation of cholecystocholedochal fistula (up to one-third CHD wall circumference is involved) type III: up to two-thirds of CHD wall circumference is involved in a cholecystocholedochal fistula type IV: entire CHD wall is involved in a cholecystocholedochal fistula type V: any of the above with cholecystoenteric fistula MRI findings: MRCP classically shows a large impacted gallstone in the gallbladder neck or cystic duct, or signs of inflamed gallbladder causing proximal dilatation of the extra and intrahepatic biliary tree, with distal gradual tapering of the extrahepatic biliary duct caliber to the site of obstruction. Complications: Prolonged biliary obstruction and inflammation may lead to: Cholecystobiliary fistula: leads to choledocholithiasis cholecystocutaneous fistula Gallstone ileus : if the stone passes into the small bowel through a cholecystoenteric fistula Secondary biliary cirrhosis Delayed onset biliary stricture
References:
Klekowski J, Piekarska A, Góral M, Kozula M, Chabowski M. The Current Approach to the Diagnosis and Classification of Mirizzi Syndrome. Diagnostics (Basel). 2021;11(9):1660. doi:10.3390/diagnostics11091660 - Pubmed Bellamlih H, Bouimetarhan L, En-Nouali H, Amil T, Chouaib N, Jidane S, Rafai M, Belkouch A, Belyamani L. [Mirizzi's syndrome: a rare cause of biliary tract obstruction: about a case and review of the literature]. Pan Afr Med J. 2017;27:45. - PMC - PubMed Jones M & Ferguson T. Mirizzi Syndrome. 2024. - Pubmed
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!