Challenging differential diagnosis, Management of emergency care, Rare disease, Educational Purpose (only if useful for a systematic review or synthesis)
Carolina Borz-Baba, Dylan A. Levy, Matthew E. Cohen
Department of Internal Medicine, Yale School of Medicine, St. Mary’s Hospital, Waterbury, CT, USA
Am J Case Rep 2019; 20:1290-1298
Mirizzi syndrome is biliary obstruction caused by extrinsic compression of the distal common hepatic duct by a gallstone in the adjacent cystic duct or infundibulum of the gallbladder. Post-cholecystectomy Mirizzi syndrome (PCMS) is Mirizzi syndrome in the post-surgical absence of a gallbladder. This case report of PCMS and review of the literature illustrates the diagnostic and therapeutic challenges in evaluating and managing Mirizzi syndrome.
CASE REPORT: A 44-year-old female with a remote history of laparoscopic cholecystectomy presented to a community teaching hospital with acute and severe upper abdominal pain and tenderness. Laboratory data revealed markedly elevated transaminases of a magnitude most often observed with hepatitis from acute viral infection, ischemia, or exposure to a hepatotoxin. PCMS was ultimately diagnosed at endoscopic retrograde cholangiopancreatography after being misdiagnosed as choledocholithiasis on magnetic resonance cholangiopancreatography. After transfer to an academic quaternary care referral hospital, the patient’s extrahepatic biliary tree was reportedly cleared of gallstones following endoscopically-directed shock-wave lithotripsy performed at repeat endoscopic retrograde cholangiography.
CONCLUSIONS: Recognizing post-cholecystectomy syndrome, in general, and PCMS, in particular, is critical when caring for patients presenting with persistent or recurrent symptoms or signs of biliary obstruction following cholecystectomy. Expediently identifying and definitively relieving the biliary obstruction, while limiting the risk of iatrogenic complication, is the priority when caring for patients with PCMS.
Keywords: Cholangiopancreatography, Endoscopic Retrograde, Mirizzi syndrome, Postcholecystectomy Syndrome