Endoscopic Management and Avoiding Early Surgery in a Rare Case of Type I Mirizzi’s Syndrome

Case Report

A 45-year-old male, presented to the emergency department with a history of fever, abdominal pain and jaundice for 2 weeks. He was found in septic shock, admitted to Intensive Care Unit. Blood cultures were positive for K. pneumoniae, CT of the abdomen and pelvis showed hepatomegaly, severe diffuse hepatic steatosis, no biliary duct dilation and cholelithiasis. MRCP demonstrated a small non-obstructing distal CBD calculi. The gastroenterology team performed a EUS and ERCP; it was remarkable for stones in the gallbladder neck and one stone in the distal CBD associated with 10mm dilation, findings suggestive of Mirizzi’s syndrome type I. He had a successful sphincterotomy and balloon extraction of CBD stones with evidence of bile flow, no stents were required (Figure 1 and 2).

Discussion and Conclusion

Mirizzi’s syndrome is estimated to be between 0.05 to 4 percent of all patients undergoing surgery for cholelithiasis. Mirizzi’s syndrome can be mistakenly diagnosed as cholangiocarcinoma. Mirizzi’s syndrome can present with fever, abdominal pain and jaundice. It can also be associated with acute cholangitis and pancreatitis. Diagnosis of Mirizzi’s syndrome can be suspected in any patient that presents with the mentioned symptoms with presence of an impacted stone in the gallbladder neck with dilation of biliary duct. In our case, we performed an EUS/ERCP as diagnostic and therapeutic management. ERCP and sphincterotomy allows for biliary decompression with or without stenting in a patient with obstructive jaundice as in this case. Surgery is the definitive therapy for Mirizzi’s syndrome; surgery can be avoided early in the disease course especially in patients with poor surgical candidacy. In our case patient clinically improved after treatment. He was instructed to complete the treatment for bacteremia. He was scheduled for elective cholecystectomy outpatient [6-10].

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