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Mirizzi syndrome

Renuka Umashanker, MD
Douglas Smink, MD, MPH
Section Editors
Sanjiv Chopra, MD, MACP
Stanley W Ashley, MD
Deputy Editors
Shilpa Grover, MD, MPH, AGAF
Wenliang Chen, MD, PhD


Mirizzi syndrome is defined as common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann's pouch of the gallbladder [1-3]. Patients with Mirizzi syndrome can present with jaundice, fever, and right upper quadrant pain. Mirizzi syndrome is often not recognized preoperatively in patients undergoing cholecystectomy and can lead to significant morbidity and biliary injury, particularly with laparoscopic surgery [4].

This topic reviews the epidemiology, clinical manifestations, diagnosis, and management of Mirizzi syndrome. Other complications of gallstone disease including choledocholithiasis, acute cholangitis, and acute cholecystitis are discussed separately. (See "Choledocholithiasis: Clinical manifestations, diagnosis, and management" and "Acute cholangitis" and "Acute cholecystitis: Pathogenesis, clinical features, and diagnosis".)


Prevalence — Mirizzi syndrome is estimated to occur in 0.05 to 4 percent of patients undergoing surgery for cholelithiasis [5-8]. Approximately 50 to 77 percent of patients with Mirizzi syndrome are women, which may in part be due to a higher incidence of gallstones in women. (See "Approach to the patient with incidental gallstones", section on 'Epidemiology and risk factors'.)

Association with gallbladder cancer — Mirizzi syndrome has been associated with gallbladder cancer [7,9]. It has been hypothesized that recurrent inflammation and biliary stasis may predispose to both conditions. The reported prevalence of gallbladder cancer in patients with Mirizzi syndrome undergoing cholecystectomy ranges from 5 to 28 percent [7,9]. In a retrospective study of 4800 patients who underwent cholecystectomy, Mirizzi syndrome was present in 133 patients, of whom seven (5 percent) had gallbladder cancer [9]. A preoperative diagnosis of gallbladder cancer was made in only one of seven patients. Gallbladder cancer was detected intraoperatively in one patient and only on pathologic examination of the gallbladder in five patients.


The gallbladder consists of the fundus, body, infundibulum, and neck. The body extends from the fundus into the tapered portion, or neck. The neck usually forms a gentle curve, the convexity of which forms the infundibulum, or Hartmann’s pouch. The gallbladder is connected at its neck to the cystic duct which empties into the common bile duct. Large gallstones can become impacted in the cystic duct or in Hartmann's pouch (figure 1). These stones can produce common hepatic duct obstruction by mechanical obstruction of the hepatic duct because of the proximity of the cystic duct and the common hepatic duct, and secondary inflammation with frequent episodes of cholangitis [10-12]. In rare cases, chronic inflammation may result in bile duct wall necrosis and erosion of the anterior or lateral wall of the common bile duct by impacted stones leading to cholecystobiliary (cholecystohepatic or cholecystocholedochal) fistula.

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Literature review current through: Nov 2017. | This topic last updated: Feb 28, 2017.
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  1. Witte CL. Choledochal obstruction by cystic duct stone. Mirizzi's syndrome. Am Surg 1984; 50:241.
  2. Alberti-Flor JJ, Iskandarani M, Jeffers L, Schiff ER. Mirizzi syndrome. Am J Gastroenterol 1985; 80:822.
  3. Mirizzi PL. Syndrome del conducto hepatico. J Int de Chir 1948; 8:731.
  4. Yip AW, Chow WC, Chan J, Lam KH. Mirizzi syndrome with cholecystocholedochal fistula: preoperative diagnosis and management. Surgery 1992; 111:335.
  5. Mishra MC, Vashishtha S, Tandon R. Biliobiliary fistula: preoperative diagnosis and management implications. Surgery 1990; 108:835.
  6. Corlette MB, Bismuth H. Biliobiliary fistula. A trap in the surgery of cholelithiasis. Arch Surg 1975; 110:377.
  7. Redaelli CA, Büchler MW, Schilling MK, et al. High coincidence of Mirizzi syndrome and gallbladder carcinoma. Surgery 1997; 121:58.
  8. Beltran MA, Csendes A, Cruces KS. The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification. World J Surg 2008; 32:2237.
  9. Prasad TL, Kumar A, Sikora SS, et al. Mirizzi syndrome and gallbladder cancer. J Hepatobiliary Pancreat Surg 2006; 13:323.
  10. Starling JR, Matallana RH. Benign mechanical obstruction of the common hepatic duct (Mirizzi syndrome). Surgery 1980; 88:737.
  11. Montefusco P, Spier N, Geiss AC. Another facet of Mirizzi's syndrome. Arch Surg 1983; 118:1221.
  12. Koehler RE, Melson GL, Lee JK, Long J. Common hepatic duct obstruction by cystic duct stone: Mirizzi syndrome. AJR Am J Roentgenol 1979; 132:1007.
  13. Csendes A, Díaz JC, Burdiles P, et al. Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg 1989; 76:1139.
  14. Ibrarullah M, Mishra T, Das AP. Mirizzi syndrome. Indian J Surg 2008; 70:281.
  15. Morelli A, Narducci F, Ciccone R. Can Mirizzi syndrome be classified into acute and chronic form? An endoscopic retrograde cholangiography (ERC) study. Endoscopy 1978; 10:109.
  16. Curet MJ, Rosendale DE, Congilosi S. Mirizzi syndrome in a Native American population. Am J Surg 1994; 168:616.
  17. Ibrarullah M, Saxena R, Sikora SS, et al. Mirizzi's syndrome: identification and management strategy. Aust N Z J Surg 1993; 63:802.
  18. Binmoeller KF, Thonke F, Soehendra N. Endoscopic treatment of Mirizzi's syndrome. Gastrointest Endosc 1993; 39:532.
  19. Becker CD, Hassler H, Terrier F. Preoperative diagnosis of the Mirizzi syndrome: limitations of sonography and computed tomography. AJR Am J Roentgenol 1984; 143:591.
  20. Berland LL, Lawson TL, Stanley RJ. CT appearance of Mirizzi syndrome. J Comput Assist Tomogr 1984; 8:165.
  21. Yun EJ, Choi CS, Yoon DY, et al. Combination of magnetic resonance cholangiopancreatography and computed tomography for preoperative diagnosis of the Mirizzi syndrome. J Comput Assist Tomogr 2009; 33:636.
  22. Choi BW, Kim MJ, Chung JJ, et al. Radiologic findings of Mirizzi syndrome with emphasis on MRI. Yonsei Med J 2000; 41:144.
  23. Binnie NR, Nixon SJ, Palmer KR. Mirizzi syndrome managed by endoscopic stenting and laparoscopic cholecystectomy. Br J Surg 1992; 79:647.
  24. England RE, Martin DF. Endoscopic management of Mirizzi's syndrome. Gut 1997; 40:272.
  25. Baer HU, Matthews JB, Schweizer WP, et al. Management of the Mirizzi syndrome and the surgical implications of cholecystcholedochal fistula. Br J Surg 1990; 77:743.
  26. Kwon AH, Inui H. Preoperative diagnosis and efficacy of laparoscopic procedures in the treatment of Mirizzi syndrome. J Am Coll Surg 2007; 204:409.
  27. Desai DC, Smink RD Jr. Mirizzi syndrome type II: is laparoscopic cholecystectomy justified? JSLS 1997; 1:237.
  28. Targarona EM, Andrade E, Balagué C, et al. Mirizzi's syndrome. Diagnostic and therapeutic controversies in the laparoscopic era. Surg Endosc 1997; 11:842.
  29. Sare M, Gürer S, Taskin V, et al. Mirizzi syndrome: choice of surgical procedure in the laparoscopic era. Surg Laparosc Endosc 1998; 8:63.
  30. Yeh CN, Jan YY, Chen MF. Laparoscopic treatment for Mirizzi syndrome. Surg Endosc 2003; 17:1573.
  31. Erben Y, Benavente-Chenhalls LA, Donohue JM, et al. Diagnosis and treatment of Mirizzi syndrome: 23-year Mayo Clinic experience. J Am Coll Surg 2011; 213:114.
  32. Antoniou SA, Antoniou GA, Makridis C. Laparoscopic treatment of Mirizzi syndrome: a systematic review. Surg Endosc 2010; 24:33.
  33. Tsuyuguchi T, Saisho H, Ishihara T, et al. Long-term follow-up after treatment of Mirizzi syndrome by peroral cholangioscopy. Gastrointest Endosc 2000; 52:639.