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Abstracts: CLINICAL VIGNETTES/CASE REPORTS - PANCREATIC/BILIARY

Mirizzi Syndrome Type I Complicated by Cholecystocolonic Fistula: A Rare Complication for a Rare Disease

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Alastal, Yaseen MD; Hammad, Tariq MD; Hasan, Syed DO; Alaradi, Osama MD; Nawras, Ali MD, FACG

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American Journal of Gastroenterology: October 2014 - Volume 109 - Issue - p S297
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Introduction: Mirizzi syndrome is a rare disease of the biliary tract. Cholecystocolonic fistula (CCF) is an uncommon complication of biliary diseases, occurring in 0.06%-0.14%. The combination of both diseases is extremely rare. Only 1 case of CCF was reported with Mirizzi syndrome type I. Herein we present another case of of Mirizzi syndrome type I associated with CCF. A 51-year-old female patient presented to emergency department with epigastric pain for 1 day, associated with nausea and vomiting. Past medical history was significant for hyperlipidemia and hypothyroidism. At presentation, vital signs were stable. Abdominal examination revealed epigastric tenderness with no guarding or rigidity. Bowel sounds were present. Laboratory work: white blood cell counts of 11.4 K/mm3, total bilirubin of 1.7 mg/dL, direct bilirubin of 0.4 mg/dL, and alkaline phosphatase, aspartate and alanine aminotransferase levels of 106 U/L, 584 U/L, and 915 U/L, respectively. Viral hepatitis serology was negative. Gallbladder ultrasound revealed multiple echogenic gallstones and dilated common bile duct (CBD) of 9 mm. HIDA scan showed evidence of radiotracer activity in gallbladder and possibly in the right hemicolon. CT scan showed no definite communication between the gallbladder and ascending colon. Patient underwent ERCP which revealed multiple filling defects in cystic duct (Figure 1A) causing compression of bile duct. In addition, contrast extravasation into the ascending colon was noted during occlusive cholangiogram (Figure 1B). Sphincterotomy was performed followed by biliary stenting. Patient was taken to surgery; fistula was identified from the inferior edge of the gallbladder to the hepatic flexure. Roux-en-Y hepaticojejunostomy and cholecystectomy was performed. Pathology study of the gallbladder revealed chronic cholecystitis with multiple cholelithiasis. Cholecystocolonic fistula could be a complication of Mirizzi syndrome. ERCP is essential to confirm the diagnosis and to guide further surgical management.

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Figure 1:
(A) ERCP reveals multiple filling defects in cystic duct (B) contrast extravasation into the ascending colon during occlusive cholangiogram.
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