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home - Biliary - Gallstone Disease - Mirizzi Syndrome Written by Dr Sebastian Zeki

Knows the physiology and biochemistry of bile and the pathogenesis
of gallstones

Is familiar with the normal anatomy and the anatomical variations of
the biliary tree

Recognises the symptoms and signs of the potential complications of
galllstone disease including biliary colic acute cholecystitis jaundice
due to calculous bile duct obstruction cholangitis and carcinoma

Knows the various techniques of diagnostic imaging including
ultrasound CT MRI ERCP EUS radionuclide techniques

Knows the various treatment options the indications for operative and
non-operative management and the risks of each

Knows the current national guidelines for use of ERCP and the risks
of the technique

Knows the ways in which gallbladder polyps are diagnosed and

Knows that gallbladder and sphincter of Oddi dysfunction (SOD) may
account for otherwise unexplained abdominal pain

Recognises different types of SOD how they may present and how
they are investigated

Can select the most appropriate diagnostic and therapeutic
techniques for each clinical situation

Recognises possibility of diagnostic uncertainty in biliary dysmotility
and shows thoughtful judgement in each individual situation

Makes appropriate assessment stratifies urgency and plans
management of patients who have complications of gallstones

Mirizzi Syndrome

DefinitionThis is defined as hepatic duct obstruction caused by an extrinsic compression from an impacted stone or inflammation in the cystic duct or Hartmann’s pouch. DiagnosisUSS is imaging of choice- CT rarely shows anything extra.MRCP/ ERCP is useful if there is doubt as to the cause of intrahepatic duct dilatation. Management Bilioenteric anastomo-sis is preferred since the entire wall of the common bile duct has been destroyed. Laparoscopic surgeryDifficult as lots of adhesions and inflammation so can get converted to open.Endoscopic therapyUsually temporizing measure only/ for those who aren’t for surgeryLong-term success appears to be most likely in patients with type II disease who do not have residual gallbladder stones. Mirizzi’s Syndrome Management This involves cholecystec-tomy plus common bile duct exploration with T-tube placement. Management This involves suture of the fistula with absorbable material or chole-dochoplasty with the remnant gallbladder. Management This involves choledochoplasty; suture of the fistula is not indicated. Type 2- Presence of cholecystobiliaryfistula with diameter one thirdof circumference of the commonhepatic duct wall Type 3-Presence of cholecystobiliaryfistula with diameter two thirdof circumference of the commonhepatic duct wall Type 4- Presence of cholecystobiliaryfistula which involves the entirecircumference of the commonhepatic duct wall Type 1- Stone in Hartman’s pouch/ cystic duct causing CHD obstruction Written by Dr Sebastian Zeki

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