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Mirizzi syndrome associated with hepatic artery pseudoaneurysm: a case report
© Anderson et al; licensee BioMed Central Ltd. 2008
Received: 04 September 2007
Accepted: 17 November 2008
Published: 17 November 2008
This is the first case report of Mirizzi syndrome associated with hepatic artery pseudoaneurysm.
A 54-year-old man presented with painful obstructive jaundice and weight loss. Computed tomography showed a hilar mass in the liver. Following an episode of haemobilia, angiography demonstrated a pseudoaneurysm of a branch of the right hepatic artery that was embolised. At surgery, a gallstone causing Mirizzi type II syndrome was found to be responsible for the biliary obstruction and a necrotic inflammatory mass and haematoma were found to be extending into the liver. The mass was debrided and drained, the obstructing stones removed and the bile duct drained with a t-tube. The patient made a full recovery.
This case highlights another situation where there may be difficulty in differentiating Mirizzi syndrome from biliary tract cancer.
Mirizzi syndrome  is often not diagnosed on imaging pre-operatively and is commonly mistaken for gall bladder or bile duct cancer (cholangiocarcinoma) [2–5]. Haemobilia can occur with gall bladder cancer but major haemobilia is more commonly associated with sepsis and inflammation producing a pseudoaneurysm of the hepatic artery . We describe a patient who presented with obstructive jaundice and haemobilia with imaging suggestive of gall bladder cancer and which posed a diagnostic and therapeutic challenge.
Mirizzi type II syndrome is caused by a gallstone impacting in the neck of the gallbladder eroding the wall of the cystic duct and common hepatic duct and forming a bilio-biliary fistula and obstruction to biliary drainage . Differentiating Mirizzi syndrome from gallbladder cancer or cholangiocarcinoma is a well-recognised problem and it may be impossible to establish the diagnosis pre-operatively [2–5].
Haemobilia is most commonly caused by iatrogenic trauma such as percutaneous biopsy (28%). Aneurysms account for about 10% of cases. Haemobilia can occur secondary to gallstones or neoplasia, and angiography is the most useful diagnostic modality for haemobilia .
Aneurysms of branches of the hepatic arteries are rare (0.03% in surgical admissions). At risk groups include patients following orthotopic liver transplant, abdominal trauma, pancreatic pseudocysts, polyarteritis nodosa and percutaneous liver biopsy .
In this patient, the haemobilia occurred before the percutaneous biopsies were taken. The presence of haemobilia and hepatic artery aneurysm suggested a benign rather than malignant process. Mirizzi syndrome is likely to have produced cholecystitis, gallbladder perforation and aneurysm formation secondary to sepsis and inflammation.
No case of Mirizzi syndrome has been reported with a hepatic artery pseudoaneurysm. Embolisation of the aneurysm and open cholecystectomy resulted in a good outcome for this patient. Even when symptoms, signs and radiological appearances are indicative of cancer, benign conditions should be considered when histology is unable to confirm the diagnosis.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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