Mirizzi syndrome

　　Didlake et al. emphasized that anatomical variations of the cystic duct are related to the occurrence of this condition. The pathological basis is the low opening of the cystic duct or parallel to the common bile duct; sometimes, the adjacent two tube walls are absent, only separated by a thin fibrous membrane covered with bile duct epithelium; sometimes, a sheath-like structure is formed around the cystic duct, wrapping it together with the common hepatic duct. Such stones, once impacted in the cystic duct, are very prone to compress the common hepatic duct, causing stenosis, or even forming fistulas. Other existing factors include: ①Impaction of gallbladder neck or cystic duct stones, compression of the common hepatic duct by gallbladder stones or inflammation, or inflammation involving the common hepatic duct. ②Accompanied by pericholecystitis, severe inflammatory cell infiltration in the gallbladder triangle. ③Reduction in the number of neurons in the wall of the common bile duct leads to regulatory disorders of the common bile duct.

　　In the past, many scholars believed that large stones were the main factor in the occurrence of Mirizzi syndrome. Research has found that gallstones ranging in size from 5 to 15 mm are prone to become impacted in the gallbladder neck or cystic duct, thus causing Mirizzi syndrome. They are also most likely to cause gallbladder cystic duct fistula, with an incidence rate 5.8 times higher than that of other stones. This disease is caused by complex pathological changes due to compression or inflammation of the common bile duct, and is divided into 5 stages according to the severity of the lesion: ① Narrowing of the common bile duct due to the displacement and compression of the stone. ② Impaction of gallstones and involvement of cholangitis due to gallbladder inflammation, which subsides after gallbladder resection. ③ Cholangitis, cholangitic ulcer, intraductal calculi, and stenosis of the common bile duct. ④ Formation of gallbladder cystic duct fistula. ⑤ Fibrotic stenosis and obstruction of the common bile duct. Different stages cause different clinical manifestations.

　　Mirizzi syndrome is actually a complication of cholelithiasis rather than an independent disease, and common complications include the following:

　　1. Patients with concurrent cholangitis may present with typical triad symptoms of abdominal pain, jaundice, and high fever with chills.

　　2. In cases with concurrent choledocholithiasis, duodenal papillary inflammation, and stenosis, there may be widening of the common bile duct.

　　3. Most patients have mild jaundice. The basic symptoms include yellowing of the skin, conjunctiva, and other tissues. When jaundice deepens, urine, sputum, tears, and sweat are also yellowed, while saliva generally does not change color. The color of urine and feces changes. Gastrointestinal symptoms often include bloating, abdominal pain, loss of appetite, nausea, vomiting, diarrhea, or constipation. The main symptoms of cholestatic jaundice include: itching, bradycardia, bloating, steatorrhea, night blindness, fatigue, debility, and headache. Patients may show decreased appetite, nausea, aversion to greasy food, fatigue, dark yellow urine like tea, pain in the liver area, fever, and in a few severe hepatitis cases, bloating, oliguria, and bleeding tendency.

　　Clinical manifestations of Mirizzi syndrome are often non-specific and difficult to differentiate from choledocholithiasis. The disease is more common in the elderly, and most patients with Mirizzi syndrome have a history of gallstones, with recurrent attacks of biliary colic and jaundice. Patients with concomitant cholangitis may present with typical triad symptoms of abdominal pain, jaundice, and high fever with chills; most patients have mild jaundice or a history of jaundice, and some may not have jaundice. In Mirizzi syndrome, the gallbladder can become enlarged, atrophic, or remain unchanged, with the majority of reports indicating atrophy as the most common; the common bile duct can be normal, widened, or narrowed, and if complications such as choledocholithiasis/duodenal papillary inflammation/narrowing occur, there may be widening of the common bile duct.

　　Mirizzi syndrome often accompanies cholelithiasis, so the first step in preventing Mirizzi syndrome is to pay attention to the prevention and care of cholelithiasis.

　　1. Dietary regulation is the most ideal preventive method to prevent cholelithiasis and gallbladder cancer. To prevent cholelithiasis, attention should be paid to dietary regulation, and the diet should be diverse. In addition, cold and greasy foods, high-protein foods, spicy foods, and strong alcohol are prone to produce dampness and heat, causing bile stasis, and should be eaten less. Vegetables and fruits rich in vitamin A and vitamin C, fish, and seafood are helpful for clearing the gallbladder and dampness, and dissolving stones, and should be eaten more.

　　2. Live a regular life, pay attention to a balance between work and rest, regularly participate in sports activities, eat breakfast on time, avoid obesity, and reduce the number of pregnancies, which are also very important preventive measures.

　　3. If there are family members with gallstones, pay attention to related preventive health checks.

　　The clinical manifestations of Mirizzi syndrome are complex and non-specific, with no specific indicators in laboratory tests, and the detection rate of imaging diagnosis is also very low, objectively causing a low diagnosis rate of Mirizzi syndrome before surgery. All patients with a history of jaundice and gallstones should consider the possibility of Mirizzi syndrome. Abnormal liver function tests, such as elevated serum bilirubin, AST, and AKP, as well as ultrasound findings of atrophic gallbladder, 'triple sign,' or seeing an elongated cystic duct or a parallel cystic duct and common hepatic duct on ERCP or MRCP, and the 'reverse C sign' should raise high suspicion of Mirizzi syndrome.

　　1. Ultrasound examination;

　　2. Endoscopic retrograde cholangiopancreatography;

　　3. CT scan;

　　4. Magnetic Resonance Cholangiopancreatography (MRCP).

　　Currently, it is believed that MRCP is the best examination method for diagnosing Mirizzi syndrome.

　　Mirizzi syndrome is actually a complication of cholelithiasis, not an independent disease. For patients with gallstones, there are many taboos after getting gallstones, especially in terms of diet and lifestyle.

　　1. Avoid soups and mayonnaise with high fat content.

　　2. Keep the taste as light as possible, and be moderate with seasonings.

　　3. Limit the intake of cholesterol. Absolutely avoid foods rich in cholesterol, such as internal organs and egg yolks.

　　4. Milk should only be consumed in its skimmed form.

　　5. Avoid processed foods and foods high in sugar.

　　6. Avoid overeating and binge drinking.

　　7. Avoid foods that are prone to produce gas. Examples include potatoes, sweet potatoes, legumes, onions, radishes, carbonated beverages, as well as acidic juices, coffee, and cocoa.

　　8. Avoid foods with strong刺激性, such as chili, curry, and mustard greens, and refrain from alcohol, coffee, and strong tea.

　　9. Minimize the use of frying and frying methods in cooking, and opt for boiling, stewing, and steaming instead.

　　10. Avoid smoking, alcohol, and coffee to prevent stimulation of the bile duct sphincter, causing sphincter spasm and difficulty in bile excretion.

　　11. Avoid spicy and alcoholic foods. Patients with cholecystitis and gallstones should not only pay attention to the fineness and ease of digestion of food, eat small and frequent meals, but also avoid spicy and alcoholic stimulant foods to reduce or avoid stimulation of the gallbladder. In summary, the dietary arrangements for patients with cholecystitis and gallstones are not only suitable for acute attacks, but should also be maintained during the quiescent period or recovery period to prevent recurrence.

　　12. Consume adequate high-quality protein. If a person does not consume animal products for a long time, the body is bound to lack protein and other nutrients to varying degrees, leading to malnutrition, decreased resistance, and susceptibility to illness, which is also不利于 the recovery of patients with cholecystitis and gallstones. Therefore, consuming adequate high-quality protein is completely necessary. Lean meat, poultry, fish, eggs, and soy products are rich in high-quality protein.

　　The clinical manifestations of Mirizzi syndrome are complex and non-specific, with no specific indicators in laboratory tests, and a very low detection rate in imaging diagnostic tests. Objectively, this causes a low preoperative diagnosis rate of Mirizzi syndrome. Below, I will introduce the specific treatment methods.

　　1. Endoscopic Treatment

　　In the past, due to the inability of endoscopes to approach and remove stones embedded in the gallbladder neck, they were not suitable for the treatment of Mirizzi syndrome. However, with the progress of endoscopic sheath instruments and technology, some progress has been made in endoscopic treatment of Mirizzi syndrome.

　　2. Surgical Treatment

　　The central issue during Mirizzi syndrome surgery is to avoid bile duct injury and correct existing bile duct injuries and stricture. The treatment principle should be to remove the diseased gallbladder, remove all stones, relieve bile duct compression and obstruction, repair bile duct defects, and ensure smooth bile drainage.

　　3. Laparoscopic Cholecystectomy (LC)

　　With the accumulation of laparoscopic surgery experience, the improvement of surgical techniques, and the update of surgical instruments, laparoscopic cholecystectomy (LC) has made significant breakthroughs in dealing with Mirizzi syndrome. However, many scholars do not advocate the use of laparoscopy for the treatment of Mirizzi syndrome due to the anatomical variations of the gallbladder triangle in patients with Mirizzi syndrome and severe fibrous adhesions.