Mirizzi syndrome
Introduction
Introduction to Mirizzi Syndrome Mirizzi syndrome (Mirizzisyndrome) is not commonly seen clinically as a biliary obstructive disease caused by gallbladder neck or cystic duct stones and its inflammation. basic knowledge Sickness ratio: 0.05% Susceptible people: no special people Mode of infection: non-infectious Complications: abdominal pain, jaundice, common bile duct stones, jaundice
Cause
Causes of Mirizzi syndrome
Anatomical variation of the cystic duct (36%):
Didlake et al. emphasized that the anatomical variation of the cystic duct is related to the occurrence of the intrinsic disease. The basis of the lesion is: the cystic duct opening is too low or parallel to the common bile duct; the adjacent two walls are sometimes absent, and only one layer of thin fibrous membrane covered with bile duct epithelium is separated. Sometimes the surrounding tissue forms a sheath-like structure, and the cystic duct is wrapped together with the common hepatic duct. Once the stone is invaded in the cystic duct, it is easy to compress the common hepatic duct to make it narrow or even form a hernia. Other factors exist. and also:
Large stones (26%):
Many scholars have previously believed that large stones are the main factor in the occurrence of Mirizzi syndrome. It has been found that gallstones with a size of 5 to 15 mm are easily invaded in the gallbladder neck or cystic duct, resulting in Mirizzi syndrome.
Gallbladder inflammation (15%):
Gallbladder neck or cystic duct stones incarcerated, gallstones or inflammation compression of the common hepatic duct or inflammation involving the common hepatic duct.
1. With inflammation around the gallbladder, the gallbladder triangle has severe inflammatory cell infiltration.
2. Due to the decrease in the number of neurons in the common bile duct wall, the common bile duct regulation disorder.
Pathogenesis
Tian Yifeng and other studies believe that the size of the stone is related to the onset of Mirizzi syndrome. The diameter of the stone is 0.5-1.5cm, and the incidence of incarceration is the highest. It is also the most likely to cause gallbladder bile duct fistula. The incidence of hernia is 5.8 times that of other stones. Huang Zhiqiang believes that this The disease is due to the complex pathological changes caused by the pressure of the common hepatic duct or the spread of inflammation. According to the severity of the lesion, it is divided into five stages:
1. Due to the pressure of the stone, the common hepatic duct is narrowed.
2. Gallbladder stone incarceration and gallbladder inflammation affect the bile duct, inflammation disappears after cholecystectomy.
3. Cholangitis, bile duct ulcers, intra-biliary stones, and common hepatic duct stenosis.
4. Cause gallbladder bile duct fistula.
5. Scarring stenosis of the common bile duct fibers, obstruction, different stages lead to different clinical manifestations.
Prevention
Mirizzi syndrome prevention
Prevention: Maintain a happy spirit, exercise properly, rationally arrange and regulate diet, actively prevent and treat biliary ascariasis, diabetes, nephritis, hemolytic disease, control infection, do not take long-term antihypertensive drugs, control female hormones, strictly Master the correct operation.
Complication
Mirizzi syndrome complications Complications, abdominal pain, jaundice, common calculus, jaundice
1. Patients with concurrent cholangitis may have typical abdominal pain, jaundice, high fever and chills triad.
2. Complicated with common bile duct stones / duodenal papillitis / stenosis can have widened common bile duct.
3. Most patients have mild jaundice.
Symptom
Mirizzi syndrome symptoms common symptoms high fever chills abdominal pain jaundice biliary colic volume shrink
Clinically, Mirizzi syndrome has many specific symptoms and signs. The clinical manifestations are indistinguishable from common bile duct stones. This disease is more common in the elderly. Most patients with Mirizzi syndrome have a history of gallstones, recurrent biliary colic and jaundice. Patients with concurrent cholangitis may have typical abdominal pain, jaundice, high fever and chills triad; most patients have a history of mild jaundice or jaundice, and no jaundice. England et al reported 25 patients with Mirizzi syndrome, 19 of whom had obstruction. A history of jaundice, 4 patients with a history of cholangitis, Myrian et al reported that in 17 patients, 12 patients had recurrent biliary colic, 10 patients with obstructive jaundice, and 6 patients with cholangitis, patients with Mirizzi syndrome. Gallbladder can be enlarged, atrophy, or no change, most reports of gallbladder atrophy; the common hepatic duct can be normal, widened or narrow, if the common bile duct stones / duodenal papillitis / stenosis can have common bile duct widening In general, there is no specific change in the gallbladder and bile duct.
The relationship between Mirizzi syndrome and gallbladder cancer has been paid more and more attention. Redaelli et al reported 1759 cases of cholecystectomy, and 18 cases of Mirizzi syndrome were diagnosed. Among them, 5 cases of gallbladder cancer were found, accounting for 27.8%. In gallstone surgery, there is a difference of less than 2% in gallbladder cancer. There are 12 cases in which the tumor-associated antigen CA199 is higher than normal in 18 cases of Mirizzi syndrome, and 5 cases of gallbladder cancer are more common. Significantly increased, which indicates that Mirizzi syndrome has a certain relationship with tumor malignant transformation. The reason may be that long-term chronic stimulation of gallstones leads to mucosal hyperplasia, degeneration and carcinogenesis. Therefore, preoperative diagnosis or intraoperative gallbladder cryosection is important. .
Clinically, Mirizzi syndrome is more typed. In 1982, Mcsherry et al. classified Mirizzi syndrome into 2 types according to ERCP: type I was stone incarcerated in the cystic duct/neck external pressure hepatic duct and caused jaundice; Some or all of the stones are broken into the common hepatic duct to form the common hepatic duct of the gallbladder. The type I is further divided into two subtypes: the type IA is the cystic duct parallel to the common hepatic duct, the length of the cystic duct is >3 cm; the type IB is the cystic duct is completely Blocking, type II is divided into type IIA and type IIB: type IIA is open for bile duct fistula; type IIB is formed by incarceration of stones at the mouth of the fistula to form pseudobiliary fistula, and the fistula is found after the stone is taken in operation. In 1989, Csendes et al. The extent of gallbladder bile duct fistula and internal hemorrhoids caused by bile duct wall damage is divided into 4 types: type I is cystic duct or neck stone incarcerated hepatic common duct, also called Mirizzi syndrome prototype; type II is gallbladder bile duct fistula formation, fistula caliber < gallbladder 1/3 of the circumference of the general canal; type III is the formation of gallbladder bile duct fistula, fistula diameter > 2/3 of the common bile duct circumference; type IV is gallbladder bile duct fistula completely destroys the common bile duct wall, but England et al believe that preoperative biliary tract It is impossible to measure the size of sputum by contrast, and propose Csendes typing. In fact, in 1997, Nagakawa et al. divided Mirizzi syndrome into the following four types from the perspective of diagnosis and treatment: type I, gallbladder neck, cystic duct incarcerated stones caused by common hepatic stenosis; type II, cystic duct, gallbladder neck Incarcerated stones, the formation of gallbladder hepatic duct fistula; type III, due to the three-tube junction at the junction of the common hepatic stenosis; type IV, cystic duct, gallbladder neck without stones incarceration, and cholecystitis caused by the common hepatic duct stenosis, some people will Mirizzi Syndrome is divided into 3 types: type I is cystic duct or gallbladder neck stone incarceration type; type II is gallbladder bile duct type; type III stone incarceration and gallbladder bile duct type, and some other types, in short, Mirizzi synthesis The classification of the levy has not yet reached a consensus, and the Csendes classification is currently widely used.
Examine
Examination of Mirizzi syndrome
Abnormal liver function, such as serum bilirubin, AST, AKP increased.
1.B-Super BUS examination is non-invasive, safe, fast, inexpensive and reproducible. It is often used as the first examination method for Mirizzi syndrome and has screening value. B-ultrasound is the first choice for diagnosis of Mirizzi syndrome. Main image features There are the following points:
(1) Most patients have gallstones. The stones are located in the gallbladder or gallbladder neck. The gallbladder wall is thickened, the gallbladder is dilated, and the atrophy or gallbladder size is normal.
(2) The common hepatic duct above the opening of the cystic duct, the intrahepatic bile duct is dilated or not expanded.
(3) The diameter of the common bile duct is normal.
Joseph described the diameter of the common bile duct as normal, and the dilated cystic duct, the common hepatic duct and the portal vein, the so-called "triple channel sign", and the "three tube sign" should be considered as Mirizzi syndrome, but clinically. Rarely see "three tube signs", He Xiaodong and other reports of 32 cases of Mirizzi syndrome in 23 cases of B-ultrasound, only 2 cases of "three tube signs", common hepatic stenosis and gallbladder bile duct fistula, due to the patient's gallbladder Atrophy, poor imaging, coupled with the unclear display of the common bile duct, it is difficult to judge, Mirizzi syndrome type I incarcerated stones are easy to show, the literature believes that all clinical recurrent cholangitis, obstructive jaundice and ultrasound show the gallbladder neck Or cystic duct stones, thickening of the gallbladder wall, especially BUS diagnosis found that the common hepatic duct and intrahepatic bile duct dilatation and non-expansion of the common bile duct should be highly suspected of the disease, BUS can not be used as a definitive diagnosis.
2. Endoscopic retrograde cholangiopancreatog- raphy (ERCP) Mirizzi syndrome patients with oral gallbladder contrast agent is not developed, ERCP as one of the methods of direct cholangiography, is a diagnostic method, the literature considers ERCP Expressed as:
(1) A smooth filling defect with a smooth edge at the common hepatic duct is known as anti-C sign. The hepatic duct and intrahepatic bile duct above the filling defect are significantly dilated, and the common bile duct below the defect is slightly dilated or normal. Occasionally, the common hepatic duct is pulled and displaced to form a "<" shape of the common bile duct, which is caused by the centripetal atrophy of the gallbladder.
(2) Intrinsic type I intrahepatic bile duct light to moderate dilatation, type II, III moderate to severe dilatation, with the common hepatic duct and intrahepatic bile duct dilatation, the upper segment of the complete obstruction is not developed.
(3) gallbladder atrophy, some patients with gallbladder not developed, cystic ducts with obvious expansion with stone shadows, traffic shadows between the gallbladder bile ducts, indicating the presence of internal hemorrhoids.
(4) Some patients have combined with common bile duct stones.
(5) In some patients, the lower end of the common bile duct inflammatory stenosis or stone obstruction caused poor emptying, the bile duct is not developed or poorly developed.
However, the narrowing of the common hepatic duct and the X-ray signs caused by the incarceration of the gallbladder neck or cystic duct stones are non-specific. In consideration of Mirizzi syndrome, the postoperative performance of acute cholecystitis should be excluded, cholangiocarcinoma, gallbladder cancer and liver. The possibility of benign and malignant lesions such as portal lymphadenopathy, ERCP may still miss the diagnosis of the presence of gallbladder hepatic duct fistula, Myrian et al. performed ERCP examination in 8 patients with gallbladder hepatic duct fistula, and 2 patients did not find the presence of fistula. Therefore, it can not be considered that ERCP negative completely excludes the presence of type II Mirizzi syndrome, and intraoperative cholangiography can make up for this defect. When the stenosis of the liver is severe, it is difficult to understand the bile duct in the upper part of the obstruction when the stenosis of the hepatic duct is severe. Tube angiography (PTC) is an indication, but PTC also has shortcomings. If the gallbladder and the common hepatic duct descend in parallel, the development effect is poor, and this anatomical variation is more common in Mirizzi syndrome; when the common hepatic duct obstruction is heavier The bile duct may not be developed.
3. CT (computerized tomography) CT diagnosis of Mirizzi syndrome, there are few reports in the literature at home and abroad, but CT can better show the anatomical relationship between calcium-containing stones and hilar region, which may indicate the differential diagnosis of this syndrome and other diseases. Signs, CT mainly manifested as: widening of the gallbladder neck; calcium-containing stones outside the gallbladder; an irregular cystic cavity near the gallbladder; signs of bile duct obstruction above the pancreatic segment, polyhepatic multi-tube sign in the hilar region and dilatation of the hilar region The thickening of the bile duct wall and the fat gap between the structures in the hilar region show signs of blurring and disappearance. The latter is due to the gallbladder neck or cystic duct incarcerated stones causing cystic duct dilatation, distortion and inflammation around the gallbladder, as CT does not show Calcium-containing stones, but the upper bile duct dilatation, thickening, fat gap in the hilar area is unclear and disappear, the possibility of this syndrome should also be considered, but should be differentiated from similar signs caused by tumors and other diseases, due to CT Cross-sectional limitation often does not show direct signs of gallbladder neck/tube calculus incarceration of the common hepatic duct. It has no more advantages than ultrasound, but with the development of spiral CT three-dimensional reconstruction technology and in the biliary system. The application of the disease has certain potential in the diagnosis of this syndrome, and no literature has been reported in this regard.
MR cholangio pancreatography (MRCP) MRCP as one of the new advances in clinical application of MR water imaging technology, has been widely used in the clinical diagnosis of various biliary and pancreatic duct lesions, non-invasive, safe and simple There is no need for contrast agent and X-ray irradiation. The three-dimensional reconstruction image is similar to the direct biliary pancreatic duct angiography, and can be multi-directional rotation, multi-angle observation, etc., which can further improve the preoperative diagnosis rate of biliary and pancreatic duct diseases such as Mirizzi syndrome. The image performance is similar to that of ERCP. It is characterized by intrahepatic bile duct dilatation, common hepatic duct stenosis, and stone incarceration. The obstruction level is generally in the cystic duct. Because it can observe the surrounding tissue structure and anatomy of the biliary system, it can be differentiated from other diseases. Non-invasive, will replace ERCF and PTC, currently considered: MRCP is the best method for the diagnosis of Mirizzi syndrome.
Diagnosis
Diagnosis and differentiation of Mirizzi syndrome
The clinical manifestations of Mirizzi syndrome are complex, non-specific, and there are no specific indicators in laboratory tests. The detection rate of imaging diagnosis is also very low, objectively causing a low diagnosis rate of Mirizzi syndrome before surgery. Patients with history of gallstones should consider the possibility of Mirizzi syndrome, laboratory tests for abnormal liver function, such as serum bilirubin, AST, AKP elevation, B-ultrasound atrophic gallbladder, "three tube sign" or ERCP, MRCP Seeing that the cystic duct is too long or the cystic duct is parallel with the common hepatic duct, the "anti-C sign" is highly suspected of Mirizzi syndrome.
The differential diagnosis of Mirizzi syndrome is mainly difficult to distinguish from primary sclerosing cholangitis, both of which are obstructive jaundice, but most of them are accompanied by intestinal inflammatory diseases. Some or all of the extrahepatic biliary imaging can be seen. The bile duct ring is narrow, the intrahepatic bile duct is often involved, the degree is more serious than the extrahepatic, the mildly dilated bile duct is bead-like, and the other is the identification of biliary tumors. The general condition of patients with cholangiocarcinoma is poor, and the jaundice is progressively aggravated. Irreversible, CT scan is helpful for identification; choledocholithiasis can be ruled out by imaging examination, and traumatic or iatrogenic bile duct stricture can be ruled out through medical history.
