Unusual Case of Mirizzi Syndrome Presenting as Painless Jaundice

Abstract

Patient: Male, 60-year-old Final Diagnosis: Mirizzi syndrome Symptoms: Dark stools • jaundice • painless jaundice Medication: — Clinical Procedure: ERCP with stent placement • spyglass cholangioscopy Specialty: Gastroenterology and Hepatology Objective: Unusual clinical course Background: Isolated painless jaundice is an uncommon presenting sign for Mirizzi syndrome, which is typically characterized by symptoms of acute or chronic cholecystitis. We report a rare case of Mirizzi syndrome with an acute onset of painless obstructive jaundice. Case Report: A 60-year-old man with an unremarkable prior medical history presented with 1 week of jaundice, dark urine, and acholic stools. His laboratory studies revealed a pattern of cholestasis with marked direct hyperbilirubinemia. Ultrasound and magnetic resonance imaging studies demonstrated intrahepatic ductal dilation and cholelithiasis, including a stone within the cystic duct. Endoscopic retrograde cholangiopancreatography with SpyGlass cholangioscopy confirmed the diagnosis of Mirizzi syndrome. Conclusions: An atypical presentation of Mirizzi syndrome should be suspected in the setting of biliary obstruction without pain. The differential diagnosis is broad and includes choledocholithiasis, ascending cholangitis, and hepatobiliary malignancy. Evaluation should include laboratory studies and biliary tract imaging. Noninvasive biliary tract imaging can help exclude malignancy and confirm ductal dilation but is not sensitive for Mirizzi syndrome. Endoscopic retrograde cholangiopancreatography can serve both diagnostic as well as therapeutic purposes via stone extraction and stent placement. SpyGlass cholangioscopy can also augment management in the form of Electrohydraulic lithotripsy. Although therapeutic biliary endoscopy can be very effective, cholecystectomy remains the definitive treatment for Mirizzi syndrome.

Gallbladder Mysteries: A Diagnostic Dilemma in Mirizzi Syndrome With Acalculous Presentation

“…It appears in about 0.35% of surgical cholecystectomies [ 6 ]. There may be a slight tendency for females and older populations, but recent studies have shown no male or female predilection [ 3 ]. More than 25% of MS patients are at risk for gallbladder cancer [ 7 ].…”

“…This condition is triggered by the presence of a gallbladder neck stone or a cystic duct stone, which, with or without a cholecystocholedochal fistula, exerts pressure on the common hepatic duct [ 2 ]. In the United States, approximately 20 million people are afflicted by cholelithiasis, and MS is an infrequent complication, affecting approximately 0.1% of these individuals [ 3 ].…”

Type I Mirizzi syndrome treated by electrohydraulic lithotripsy under the direct view of SpyGlass: A case report

“…SpyGlass requires only one surgeon to operate and directly visualize all bile ducts, which enables one surgeon to perform definitive diagnosis and treatment in a single surgery. The SpyGlass surgery has been validated to be clinically feasible, which not only can be used for clinical diagnosis but also provides sufficient samples for histological analysis and successfully guides electrohydraulic and laser lithotripsy[ 10 - 14 ]. Electrohydraulic lithotripsy relies on high-pressure shock waves between working electrodes but is not operated under direct vision, thus causing the risk of bile duct injury.…”