Mirizzi Syndrome can Mimic Cholangiocarcinoma

Abstract

Introduction: Mirizzi syndrome (MS), extrinsic compression of the common hepatic duct (CHD) by a stone impacted in Hartman's pouch or cystic duct, is often not recognized preoperatively.1 This leads to significant morbidity and biliary injury.2 Typical symptoms include jaundice, fever, and RUQ pain. In this report, we present a patient with obstructive jaundice with high suspicion for cholangiocarcinoma (CCA) until he underwent a resection. Case presentation: A 75-year-old man with PMH of diverticulitis, resolved HBV infection, CAD, HTN, hyperlipidemia presented to the ED with epigastric/RUQ pain, jaundice, anorexia, and nausea of 3 week duration. The patient endorsed a 15-pound weight loss over two months, but denied fevers or chills. He consumes three alcoholic beverages per week for multiple years. Family history was positive for colon and breast cancers in his mother and skin and laryngeal cancers in his brother. Vitals WNL. Physical exam: scleral icterus, mild tenderness in the RUQ; negative murphy, negative fluid wave or organomegaly. Labs: CBC/BMP/Lipase/Amylase WNL. Total bilirubin 10.9, direct bilirubin 4.4, ALP 508, gamma-GT 320, AST 184, ALT 274. US: gallstones-containing contracted gallbladder. CBD 7 mm. no cholecystitis. Murphy negative. MRCP: no mass, thickening of the intrahepatic right hepatic duct and CHD, contract gallbladder with gallstones, compression of CBD at hilum. ERCP: high-grade stricture in CHD at the level of the confluence, cystic duct not visualized. Stent was inserted. Brushings showed atypical cells. Patient underwent excision of extrahepatic bile duct, segmental liver resection and hepaticojejunostomy. Pathology report: positive for cystic duct obstruction with a stone and negative for neoplasm. Discussion: MS can be confused with CCA (as in the patient we described above). Although MRCP is the test of choice with highest sensitivity, MS can still be misdiagnosed preoperatively. Therefore, high suspicion is needed in patients with obstructive jaundice particularly with a history of cholelithiasis. Conclusion: Mirizzi syndrome can mimic cholangiocarcinoma and high suspicion is needed.