S3317 Mirizzi on the “Rize”: A Case Series on the Endoscopic Management and Outcomes in Mirizzi Syndrome From a Community Hospital System

Introduction: Mirizzi Syndrome (MS) is a rare and often under-recognized condition characterized by extrinsic compression of the common hepatic duct (CHD) or common bile duct (CBD) due to an impacted gallstone in the cystic duct or Hartmann’s pouch. The clinical presentation frequently overlaps with other hepatobiliary conditions, which can lead to delayed recognition. This case series highlights our institutional experience in managing MS, emphasizing the pivotal role of endoscopic intervention in diagnosis and treatment. Case Description/Methods: A 42-year-old woman presented with right upper quadrant abdominal pain. Computed tomography showed cholelithiasis and choledocholithiasis with CBD measuring 1.3 cm. The patient was afebrile. Labs showed Tbili 2.2 mg/dL, ALP 154 U/L, AST 383 U/L, and ALT 525 U/L. No leukocytosis. Lipase 23 U/L. Magnetic resonance cholangiopancreatography (MRCP) confirmed choledocholithiasis with biliary dilation up to 8 mm. Endoscopic retrograde cholangiopancreatography (ERCP) with SpyGlass with cholangioscopy revealed high-grade mid-CBD stricture at the cystic duct level caused by a large, impacted calcified stone consistent with MS. Stone fragmentation and clearance were achieved with a SpyBasket, followed by deployment of a fully covered 10 mm × 80 mm LAMS to facilitate biliary drainage. The patient underwent cholecystectomy the following day. A 66-year-old man presented with sudden onset of post-prandial diffuse abdominal pain. On arrival, he had a low-grade fever and HR 120s. Labs showed WBC 18.4 10*3/uL, lactate 3.66 mmol/L, AST 144 U/L, ALT 103 U/L, ALP 156 U/L, and Tbili of 1.5 mg/dL. Right upper quadrant U/S and MRCP demonstrated cholelithiasis without cholecystitis or CBD dilation. An endoscopic ultrasound revealed a distended gallbladder with a thickened wall, suggestive of cholecystitis, and multiple hyperechoic clustered stones within the gallbladder neck and cystic duct, pressing on the CHD, suggestive of MS. No ERCP was performed given the lack of stricture, CBD stones, and normal bilirubin. The patient underwent a successful cholecystectomy with complete resolution of symptoms and normalization of labs. Discussion: These cases exemplify the diverse presentations and management pathways of MS. Both cases showed chronic cholecystitis changes with cholelithiasis post-cholecystectomy. Although rare, MS should be considered in patients with elevated liver enzymes, obstructive jaundice, and gallstones. Early detection using advanced endoscopic techniques such as cholangioscopy and EUS is invaluable in directly visualizing the biliary tree, facilitating both diagnosis and the need for cholecystectomy in the right clinical context.