Multimodality Diagnosis of Mirizzi Syndrome

A 28-year-old male patient presented to the emergency department with complaints of right upper abdominal pain, nausea and vomiting for 2 days. The past medical history was significant for sickle cell disease and chronic hyperbilirubinemia. On presentation, vitals were stable. Physical examination revealed tenderness in the upper abdomen and guarding. Laboratories demonstrated leukocytosis, anemia, elevated liver enzymes and hyperbilirubinemia greater than baseline. The patient was then referred to radiology for ultrasound evaluation, which revealed a markedly distended gallbladder containing low level echogenic sludge and gallstones in the dependent portions (Figure A). Color Doppler image of the porta hepatis showing a distended common bile duct measuring 1.0 cm (Figure B). The patient also underwent a magnetic resonance cholangiopancreatography to further evaluate the biliary pathology, which demonstrated gallstones within a markedly distended gallbladder, extending below the inferior edge of the right hepatic lobe, as seen on coronal T2 weighted image (T2WI) (Figure C). Axial T2WI magnetic resonance image illustrates a filling defect in the cystic duct consistent with a stone (Figure D; thick yellow arrow). The maximum intensity projection magnetic resonance cholangiopancreatography image provides a global image of dilated central intrahepatic biliary tree, abruptly terminating at the mid common bile duct (Figure E). Intraoperative fluoroscopic images obtained during endoscopic retrograde cholangiopancreatography confirmed dilatation of the intrahepatic biliary system (Figure F), which was secondary to a cystic duct stone. Subsequently a common bile duct stent was placed (Figure G).