Calculos Biliares

Surg Clin N Am 88 (2008) 1345–1368

Complications of Gallstones: The Mirizzi
Syndrome, Gallstone Ileus,
Gallstone Pancreatitis, Complications
of ‘‘Lost’’ Gallstones
Jill Zaliekas, MD, J. Lawrence Munson, MD*
Department of General Surgery, Lahey Clinic Medical Center,
Tufts University Medical School, 41 Mall Road, Burlington, MA 01805, USA

Mirizzi syndrome (MS) is a form of obstructivejaundice, first described
by Mirizzi [1] in 1948 caused by a stone or stones impacted in the neck of the
gallbladder or the cystic duct, such that the common hepatic duct is narrowed. Depending upon the degree of impingement and the chronicity of
the condition, there may be a cholecysto–choledochal fistula. This rare complication of gallstones occurs in about 0.1% to 0.7% of patients who havegallstones [2,3]. There is also a greater risk of gallbladder cancer found in
these patients, upwards of 25% [4]. The condition was classified by
McSherry and colleagues [5] into types 1 and 2 in 1982, and reclassified
by Csendes and colleagues [6] in 1989 into classes 1 through 4. There
must be four components for the syndrome to occur:
1. Anatomy placing the cystic duct parallel to the commonhepatic duct
2. Impaction of a stone in the cystic dust or gallbladder neck
3. Obstruction of the common hepatic duct from the stone itself, or from
the resultant inflammatory response
4. Intermittent or constant jaundice occasionally causing cholangitis, and
with longstanding obstruction, biliary cirrhosis [7]
The McSherry classification of Mirizzi syndrome based on endoscopic
retrogradecholangiopancreatography (ERCP) is broken down into:
Type 1: external compression of the common hepatic duct by calculus in
the cystic duct or Hartmann’s pouch

* Corresponding author.
E-mail address: john.l.munson@lahey.org (J.L. Munson).
0039-6109/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.suc.2008.07.011
surgical.theclinics.com

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ZALIEKAS &MUNSON

Type 2: a cholecysto–choledochal fistula is present, caused by calculus
eroding partially or completely into the bile duct [5]
The Csendes classification of Mirizzi syndrome (Fig. 1) is broken down as
follows:
Type 1: external compression of the common bile duct
Type 2: a cholecystobiliary fistula is present involving less than one third
the circumference of the bile duct
Type 3: afistula is present involving up to two thirds the circumference of
the bile duct
Type 4: a fistula is present with complete destruction of the wall of the
bile duct [6]

Diagnosis of Mirizzi syndrome
Symptoms of MS are essentially those of cholecystitis or choledocholithiasis. Most patients present with epigastric or right upper quadrant
pain, jaundice, and elevated liver function tests [8]. Theymay have episodic
pain like biliary colic, or manifest systemic symptoms of fever, chills, tachycardia, and anorexia. The condition may be intermittent and relapsing, or
fulminant, presenting as cholangitis. Imaging is, thus, essential to preoperative diagnosis, and in a literature search, the correct diagnosis was made in
8% to 62% of patients until ERCP was used regularly [9]. Most patientsFig. 1. Classification of Mirizzi’s syndrome (upper panel). Bile duct reconstruction options are
shown (lower panel). (Courtesy of Lahey Clinic, Burlington, MA; with permission.)

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who have suspected biliary tract disease undergo ultrasound as a first test,
with MRI or CT often following. Cholangiography, either percutaneous,
or endoscopic, is performedwhen liver function tests are sufficiently abnormal [10,11]. The most sensitive test for MS is ERCP, which has allowed
100% correct preoperative diagnosis to Yeh’s group (Figs. 2 and 3) [12].
In addition to making the diagnosis, the endoscopist also can palliatively
stent the jaundiced patient to allow planned exploration in a more stable
patient (Fig. 4). The authors’ belief is that any...