S3344 A Rare Case of Mirizzi-Like Syndrome in a Gastric Sleeve Patient With Recent GLP-1 RA Dosage Increase

Introduction: Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have gained prominence for clinical benefits ranging from improved glycemic control and weight loss to cardiovascular risk reduction and renal protection. However, several landmark studies on GLP-1 RAs have also reported increased incidence of biliary disease, including increased rates of cholelithiasis and cholecystitis. Here, we present a case of severe acalculous cholecystitis resulting in Mirizzi-like syndrome after GLP-1 RA dose escalation. Case Description/Methods: A 63-year-old man with obesity, atrial fibrillation, hypertension, hyperlipidemia, GERD, and sleeve gastrectomy presented to the emergency room with 1 day of nausea, abdominal pain, and diaphoresis. Initial vitals revealed a temperature of 36.2°C, heart rate 108, respiratory rate 22, and his exam was notable for tenderness to palpation in the epigastrium. Labs indicated an acute liver injury with total bilirubin 9.0/direct bilirubin 5.1, AST 1831 U/L, ALT 1812 U/L, ALK 160 U/L, lactate 4.9, and lipase 47. Viral hepatitis labs, urine drug screen, acetaminophen and ethanol levels were all unremarkable. Computed tomography abdomen/pelvis showed hydropic gallbladder with wall thickening and fat stranding without hepatobiliary ductal dilation. Subsequent MRCP demonstrated compression of the common hepatic duct due to distension of the gallbladder up to 4.5 cm in diameter. Blood cultures were positive for Klebsiella oxytoca. The patient underwent a laparoscopic cholecystectomy the next day revealing gangrenous cholecystitis without stones or obstruction noted on intraoperative cholangiogram. On day 1 post-op, his symptoms resolved, liver function tests improved, and he was discharged home on a 7-day course of levofloxacin and metronidazole. Notably, the patient stated he had lost 16 pounds since starting tirzepatide 3 months prior, and his dose was increased from 2.5 mg to 5 mg 1 week before presentation. Discussion: Common hepatic duct compression from acalculous cholecystitis described as a “Mirizzi-like” or acalculous Mirizzi syndrome after GLP-1 RA dose increase is a novel finding and could be related to inhibition of CCK by GLP-1. This case highlights the increased risk of biliary pathology with GLP-1 RA use, particularly during dose escalations. We recommend that providers consider the risk association between GLP-1 RA use and hepatobiliary pathology before prescribing and educate patients about possible biliary complications of GLP-1 RA use.