Complications of gallstone disease: mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus

Abstract

Gallstone is a common disease with a 10% prevalence in the United States and Western Europe. However, it is only symptomatic in 20-30% of patients, with biliary pain "colic" being the most common symptom. Complications of asymptomatic gallstone disease are generally rare, with an incidence of <1 %/yr. The most common complications of gallstone disease are acute cholecystitis, acute pancreatitis, ascending cholangitis, and gangrenous gallbladder. Less frequent complications include Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Mirizzi syndrome and cholecystocholedochal fistula are two manifestations of the same process that starts with impaction of a gallstone in the gallbladder neck that results in obstruction of the bile duct, causing jaundice. The gallstone may erode into the bile duct, causing cholecystocholedochal fistula. Gallstone ileus refers to small bowel obstruction resulting from the impaction of one or more gallstones after they have migrated through a cholecystoenteric fistula. An accurate diagnosis is essential to the management and prevention of further complications. A variety of imaging and endoscopic modalities are used to make the diagnosis once the condition is suspected clinically. Treatment should be tailored to each individual patient. Management choices include ERCP, lithotripsy (endoscopic or extracorporeal), and surgery. Prognosis is frequently related to early recognition, management of any comorbid conditions, and careful selection of treatment modalities.

Mirizzi Syndrome Complicating Acute Cholecystitis: CT Diagnosis

“…The main utility of computed tomography would be the exclusion of any malignancy of the bile ducts or liver [3] The MRI clearly shows the presence of gallstones or otherwise in cystic duct and associated dilatation of the common bile duct with or without intra hepatic bile duct dilatation [3]. It is very useful as it is non invasive hence avoiding complications associated with endoscopic cholangiography (ERCP) [10].…”

“…Chronic forms exist even though clinical presentation remains nonspecific. Typically, it presents as obstructive jaundice (60% -100%), accompanied by right upper quadrant pain (50% -100%) with fever suggestive of acute cholangitis [3].…”

“…Ultrasound shows a distended gallbladder with a thickened or normal wall and the presence of oneor more stones in the infundibulum [8]. The common bile duct is dilated with or without intra hepatic duct dilatation [3]. Positive diagnosis of Mirizzi syndrome on ultrasound may be achieved in 29% of cases [9].…”

“…Mirizzi syndrome is a rare pathological entity in the West with an incidence of less than 1% per year [3]. However, in developing countries, especially in Latin America, Mirizzi syndrome remains a common occurrence, with an incidence ranging from 4.7% to 5.7% [4] [5].…”

Divided Laparoscopic Cholecystectomy for Unusual Gall Stones Complication of Mirizzi’s Syndrome

“…These complications are being encountered in 1% to 2% of patients with symptomatic cholelithiasis according to some recent series (2,3). However, in underdeveloped countries, Mirizzi's syndrome is a more common condition with reported incidence ranging from 4.7% to 5.7% (4,5).…”