MIRIZZI SYNDROME: A CHALLENGING DIAGNOSIS. CASE REPORT francois_boks@yahoo.fr

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MIRIZZI SYNDROME: A CHALLENGING DIAGNOSIS. CASE REPORT

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Kenya

Poster with Discussion

Mirizzi syndrome is an uncommon side effect of gallstones. It is a challenging disorder to diagnose and treat, which presents a unique "challenge" for hepatobiliary surgeons

A 72-year-old female presented with chronic intermittent right upper quadrant pain associated with bilious vomiting. There was progressive jaundice associated with dark urine but no pruritus nor pale stools. Labs showed leukocytosis and cholestatic picture. CT and MRCP done suggested calculous cholecystitis and obstructive choledocholithiasis. Biliary stenting and stone extraction were done via ERCP and scheduled for laparoscopic cholecystectomy few weeks later after a course of antibiotics. Intraoperatively, extensive adhesions, a cholecystoduodenal fistula, an impacted cystic duct stone and Strasberg A injury prompted conversion to an open procedure. A diagnosis of type 5 Mirizzi syndrome was made. She then benefitted from subtotal cholecystectomy, modified Cellan-Jones repair for duodenal fistula, primary repair of the cystic duct leak and the massive stones were removed. A drain was left in-situ for 10 days, was discharged and is doing well on follow up.

The significance of this disease stems from the technical challenge of locating the cystic duct during cholecystectomy, increasing the likelihood of bile duct injury (about 17%), therefore a preoperative diagnosis is crucial. ERCP the gold standard for diagnosis has a diagnostic accuracy between 55-90%

Preoperative diagnosis though crucial to avoid complications is relatively difficult to make. Combining imaging tests is recommended for adequate management. Clinicians should have a high index of suspicion.