P0095 - An Atypical Presentation of Mirizzi Syndrome

Ana Maria Davila, MD, Dauris Rosario, MD, Zoë Post, MD, Ajaypal Singh, MD
Rush University Medical Center, Chicago, IL

Introduction: Mirizzi Syndrome (MS) is defined by extrinsic biliary compression secondary to an impacted gallstone at the cystic duct or gallbladder infundibulum and typically presents as abdominal pain and jaundice. We present an atypical presentation of MS with painless jaundice.

Case Description/Methods: A 72-year-old man with history of diverticulitis and GERD presented to an outside hospital with new onset jaundice, fevers, and one week of acholic stools. Initial tests showed total bilirubin of 2.8 mol/L, alkaline phosphatase (ALP) 194 U/L, aspartate aminotransferase (AST) 104 U/L and alanine aminotransferase (ALT) 168 (U/L). Computed tomography (CT) imaging showed gallbladder neck cholelithiasis and common bile duct (CBD) dilation 7mm. Magnetic resonance cholangiopancreatography (MRCP) showed a large gallstone within the cystic duct measuring 1.4 cm with mass effect on CBD and no evidence of choledocholithiasis consistent with MS. Endoscopic ultrasound (EUS) with endoscopic retrograde cholangiopancreatography (ERCP) showed a smooth bile duct stricture with upstream biliary dilatation and cholangiographic appearance. One 10Fr x 5 cm double pigtail stent was placed into the bile duct with normalization of liver function tests and symptoms. Surgery was consulted for cholecystectomy which was planned for one month post-discharge.

Discussion: MS is a rare complication of cholelithiasis, characterized by extrinsic bile compression secondary to an impacted gallstone at the gallbladder infundibulum or cystic duct. It is seen in less than 1% of cases, usually with history of cholelithiasis. Usual presentation includes abdominal pain, fever, nausea, and vomiting. Diagnostic tools include abdominal ultrasound (US) and CT abdomen, however, MRCP can demonstrate extrinsic bile duct compression and fistulas if present. ERCP serves both as a diagnostic and therapeutic tool for gallstone removal and stent placement if needed. However, therapeutic decompression by papillotomy and stent or nasal bile drainage (NBD) can also be achieved during ERCP. Our case demonstrates a rare presentation of MS with acute and painless jaundice in a patient without prior gallstones. Hence, MS should be considered in cases of painless biliary obstruction. Early detection of MS can help prevent long-standing complications of the disease, such as fistulas.


Disclosures:


Ana Maria Davila, MD, Dauris Rosario, MD, Zoë Post, MD, Ajaypal Singh, MD. P0095 - An Atypical Presentation of Mirizzi Syndrome, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.