Case Presentation:

Acute cholecystitis is a very common disease, suspected by the patient’s history and physical examination, confirmed by ultrasonographic imaging, and supported by lab findings suggestive of obstructive jaundice. Our patient had an atypical presentation of cholecystitis, secondary to her atypical anatomy.

We present a 61 year old Hispanic woman with past medical history of hyperlipidemia, migraine headaches and gastritis who presented with diffuse, pressure-like abdominal pain for 7 days, which was aggravated by movement, and mildly relieved by ibuprofen without any correlation to food. This was associated with nausea, vomiting and anorexia. On examination, she appeared septic with mild tenderness in the right upper quadrant of the abdomen with normal bowel sounds. She was found to have hyperbilirubinemia, elevated transaminases and elevated alkaline phosphatase with borderline leukocytosis. A CT scan of the abdomen was performed revealing a large hepatic sub-capsular fluid collection, along with fatty liver and mild scattered ascites and a decompressed gall bladder. She was treated with broad spectrum antibiotics and needle aspiration of the biloma. Despite drainage, her liver enzymes were persistently elevated, so an ERCP was performed. This revealed biliary stones in the common bile duct (CBD) and large stones at the insertion of the cystic duct into the CBD with leakage of contrast at the site that should be the gallbladder. A surgical consult was obtained and the patient underwent exploratory laparotomy exposing a contracted gallbladder within the hepatic capsule, and Mirizzi morphology inserting directly onto the common bile duct in the manner of a true Mirizzi syndrome. A distal cube-shaped stone in the fundus of the gallbladder contained sharp edges causing erosion of the fundus of the gallbladder, resulting in bile leakage within the hepatic capsule. The gallbladder was then surgically resected with common bile duct repair over a T-tube.

Discussion:

The Mirizzi syndrome refers to common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann’s pouch of the gallbladder due to proximity of the cystic duct and the common hepatic duct. This may lead to cholecystobiliary fistula formation and cholangitis. Mirizzi syndrome is generally considered a contraindication to laparoscopic cholecystectomy. Approaching this type of pathology laparoscopically can lead to damage to the biliary ductal system, which can be avoided with pre-operative diagnosis.

Conclusions:

Suspect Mirizzi syndrome in a patient with cholecystitis and ultrasonographic findings of a large immovable stone in the region of neck, a contracted gallbladder with CBD dilatation above the stone, and normal CBD caliber below the stone. Improvement in short and long term outcomes have been shown with open cholecystectomy when compared to endoscopic or laparoscopic management for Mirizzi syndrome.