# Mirizzi Syndrome: The Uncommon and Overlooked Surgical Cause of Obstructive Jaundice

## TL;DR

This paper discusses a rare case of Mirizzi syndrome, a condition causing obstructive jaundice, and highlights the challenges in its diagnosis and treatment.

## Contribution

The paper emphasizes the importance of open laparotomy as a safer approach for managing Mirizzi syndrome.

## Key findings

- Mirizzi syndrome was diagnosed through MRCP showing bile duct compression by gallstones.
- Laparoscopic cholecystectomy was converted to open surgery due to complications.
- Postoperative partial small bowel obstruction was managed conservatively.

## Abstract

We present a case of Mirizzi syndrome in a patient who exhibited abdominal pain along with signs of obstructive jaundice. The minimally invasive approach was complicated, necessitating an open laparotomy, which ultimately prolonged the hospital stay. A female in her early 60s with a history of rheumatoid arthritis (on methotrexate) and hypothyroidism presented to the emergency department with jaundice as her chief complaint. Upon arrival, the patient was vitally stable. The only pertinent finding was scleral icterus. Laboratory results revealed AST of 263 U/L, ALT of 233 U/L, ALP of 1246 U/L, GGT of 342 U/L, total bilirubin of 5.8 mg/dL, and direct bilirubin of 4.6 mg/dL. Abdominal ultrasound showed dilated intrahepatic and extrahepatic bile ducts, with a common bile duct measuring 16 mm, raising concern for biliary obstruction. Magnetic resonance cholangiopancreatography (MRCP) showed marked intrahepatic ductal dilation resulting from extrinsic compression of the common hepatic duct (CHD) by impacted gallstones at the gallbladder neck, findings that are consistent with Mirizzi syndrome. Hence, endoscopic retrograde cholangiopancreatography (ERCP) was deferred and she underwent subsequent laparoscopic cholecystectomy, which turned into open surgery, and ended up getting bile duct resection with hepaticojejunostomy. Her postoperative course got complicated with partial small bowel obstruction, which was managed conservatively. Mirizzi syndrome presents a formidable diagnostic and therapeutic challenge. Our experience with this particular case reinforces that laparotomy offers a safer and more effective approach for managing Mirizzi syndrome in similar circumstances.