Overview
In 1948, P. L. Mirizzi described an unusual presentation of gallstones that, when lodged in either the cystic duct or the Hartmann pouch of the gallbladder, externally compressed the common hepatic duct (CHD), causing symptoms of obstructive jaundice.[1]
See images of Mirizzi syndrome below.
This patient presented with acute cholecystitis, as confirmed at imaging. His pain resolved over a few days, but mildly elevated bilirubin levels persisted. Image obtained during endoscopic retrograde cholangiopancreatography shows smooth narrowing of the bile duct (arrow) at the site of insertion of the cystic duct (Mirizzi syndrome). Note the small calculus in the cystic duct. Courtesy of Dr. Ali Nawaz Khan. 
Cholescintigraphy (1-h initial images) in 61-year-old man with right upper quadrant pain for 2 days. Note the nonvisualization of gallbladder and small bowel activity. Lower activity is within the urinary bladder. Courtesy of Dr. Arthur Krasnow, Department of Radiology, Medical College of Wisconsin. 
Cholescintigraphy (3-h delayed images in the anterior projection) of the same patient as in the previous image. Note persistent nonvisualization of the gallbladder and minimal activity within the small bowel. Courtesy of Dr. Arthur Krasnow, Department of Radiology, Medical College of Wisconsin. Generally, distinguishing between Mirizzi syndrome and other causes of obstructive jaundice is not possible with physical examination alone. Ultrasonography is frequently a first-line diagnostic examination. CT may also be used.[2, 3]
Radiography
Generally, plain radiography is not useful in diagnosing Mirizzi syndrome. Radiographs may depict radiopaque gallstones that contain sufficient amounts of calcium. (See the image below.)
This patient presented with acute cholecystitis, as confirmed at imaging. His pain resolved over a few days, but mildly elevated bilirubin levels persisted. Image obtained during endoscopic retrograde cholangiopancreatography shows smooth narrowing of the bile duct (arrow) at the site of insertion of the cystic duct (Mirizzi syndrome). Note the small calculus in the cystic duct. Courtesy of Dr. Ali Nawaz Khan. Potential surgical complications of a missed diagnosis obviate direct cholangiography in any patient with suspected Mirizzi syndrome after the initial evaluation with ultrasonography and/or CT. Endoscopic retrograde cholangiopancreatography (ERCP) is probably the criterion standard, and it is also useful in temporarily relieving stenosis of the common hepatic duct (CHD) by means of stent placement. Percutaneous transhepatic cholangiography (PTC) may also be used for diagnosis, especially if ERCP findings fail to help.
Common signs include visible calculus in the expected position of the cystic duct, as well as smooth, lateral, and extrinsically compressed CHD.[4]
Computed Tomography
Typical diagnostic findings of Mirizzi syndrome on CT include the following[5, 6] :
- Dilatation of the biliary system, including the CHD, distal to the level of the gallbladder neck
- An impacted calculus in the neck of the gallbladder
- A contracted gallbladder
- A normal diameter of the CBD below the level of the stone.
Signs of cholecystitis or pericholecystitis may also be present, but they are nonspecific.[6] Some authors maintain that CT should be used primarily to exclude malignancies—namely, liver metastases invading the biliary system and carcinoma of the porta hepatis—from the differential diagnosis.[7]
Yun et al measured the preoperative diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and CT for Mirizzi syndrome and found that for combined modality (MRCP and CT), the overall sensitivity was 96% (versus 42% for CT); specificity was 93.5% (CT, 98.5%); positive predictive value was 83.5% (CT, 93%); negative predictive value, 98.5% (CT, 83.5%); and accuracy was 94% (CT, 85%).[8]
Magnetic Resonance Imaging
Typical magnetic resonance cholangiopancreatography (MRCP) findings of Mirizzi syndrome include the following[9] :
- An impacted stone in the gallbladder neck
- Compression of the common hepatic duct
- Dilatation of the biliary system above the level of impaction
- A contracted gallbladder with wall-thickening.
Additional sequences should be used to exclude the presence of malignancy.
Yun et al measured the preoperative diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and CT for Mirizzi syndrome and found that for combined modality (MRCP and CT), the overall sensitivity was 96% (versus 42% for CT); specificity was 93.5% (CT, 98.5%); positive predictive value was 83.5% (CT, 93%); negative predictive value was 98.5% (CT, 83.5%); and accuracy was 94% (CT, 85%).[8]
Ultrasonography
Ultrasonographic findings include the following:
- An impacted calculus in the Hartmann pouch or the cystic duct
- Dilatation of the CHD above the level of the impacted stone
- Narrowing of the CHD at the level of impaction
- Normal caliber of the CBD below the impaction
Nuclear Imaging
Hepatobiliary iminodiacetic acid–diisopropyl iminodiacetic acid (HIDA-DISIDA) scintigraphy may be useful in diagnosing Mirizzi syndrome. Three highly sensitive and specific signs noted are a nonvisualized gallbladder, moderate dilatation of the common hepatic duct (CHD), and delayed excretion into the duodenum. (See the images below.)
Cholescintigraphy (1-h initial images) in 61-year-old man with right upper quadrant pain for 2 days. Note the nonvisualization of gallbladder and small bowel activity. Lower activity is within the urinary bladder. Courtesy of Dr. Arthur Krasnow, Department of Radiology, Medical College of Wisconsin. Cholescintigraphy (3-h delayed images in the anterior projection) of the same patient as in the previous image. Note persistent nonvisualization of the gallbladder and minimal activity within the small bowel. Courtesy of Dr. Arthur Krasnow, Department of Radiology, Medical College of Wisconsin. Angiography
Percutaneous transhepatic cholangiography (PTC) findings include the following:
- An impacted calculus in the Hartmann pouch or gallbladder neck
- Narrowed CHD at the level of impaction
- Dilatation of the CHD distal to the level of the impacted calculus
- Normal-caliber CBD proximal to the impacted calculus
Mirizzi PL. Syndrome del conducto hepatico. J Int de Chir. 1948;8:731-77.
Menias CO, Surabhi VR, Prasad SR, Wang HL, Narra VR, Chintapalli KN. Mimics of cholangiocarcinoma: spectrum of disease. Radiographics. Jul-Aug 2008;28(4):1115-29. [Medline].
Pelaez-Luna M, Levy MJ, Arora AS, Baron TH, Rajan E. Mirizzi syndrome presenting as painless jaundice: a rare entity diagnosed by EUS. Gastrointest Endosc. May 2008;67(6):974-5; discussion 975. [Medline].
Pemberton M, Wells AD. The Mirizzi syndrome. Postgrad Med J. Aug 1997;73(862):487-90. [Medline].
Nishimura A, Shirai Y, Hatakeyama K. High coincidence of Mirizzi syndrome and gallbladder carcinoma. Surgery. Sep 1999;126(3):587-8. [Medline].
Becker CD, Hassler H, Terrier F. Preoperative diagnosis of the Mirizzi syndrome: limitations of sonography and computed tomography. AJR Am J Roentgenol. Sep 1984;143(3):591-6. [Medline].
Toscano RL, Taylor PH Jr, Peters J, Edgin R. Mirizzi syndrome. Am Surg. Nov 1994;60(11):889-91. [Medline].
Yun EJ, Choi CS, Yoon DY, Seo YL, Chang SK, Kim JS, et al. Combination of magnetic resonance cholangiopancreatography and computed tomography for preoperative diagnosis of the Mirizzi syndrome. J Comput Assist Tomogr. Jul-Aug 2009;33(4):636-40. [Medline].
Oto A, Ernst R, Ghulmiyyah L, Hughes D, Saade G, Chaljub G. The role of MR cholangiopancreatography in the evaluation of pregnant patients with acute pancreaticobiliary disease. Br J Radiol. Apr 2009;82(976):279-85. [Medline].
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