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Mirizzi syndrome

Below are 10 MCQs on Mirizzi Syndrome—some basic and some advanced—covering a broad spectrum of question types. At least one question is image-based, with space provided for a hypothetical CT image to illustrate key radiological findings.

MCQ 1 (Factual / Basic)

Question

Which of the following best describes Mirizzi syndrome?

Answer Choices

A. Extrinsic compression of the common hepatic duct by an impacted gallstone in the gallbladder neck or cystic duct

B. A malignant stricture of the bile duct due to cholangiocarcinoma

C. A congenital abnormality involving fusion of the gallbladder and extrahepatic bile ducts

D. Reflux of pancreatic enzymes into the gallbladder causing chronic cholecystitis

Correct Answer: A. Extrinsic compression of the common hepatic duct by an impacted gallstone in the gallbladder neck or cystic duct.

Explanation

  • Why A is correct: Mirizzi syndrome is specifically characterized by an impacted stone in the gallbladder neck or cystic duct leading to external compression (or erosion) into the common hepatic duct.
  • Why B is incorrect: Malignant strictures (e.g., cholangiocarcinoma) are not defined as Mirizzi syndrome.
  • Why C is incorrect: There is no congenital fusion anomaly here; Mirizzi syndrome is an acquired condition.
  • Why D is incorrect: Pancreatic reflux is unrelated to the pathogenesis of Mirizzi syndrome, which involves gallstones and inflammation.

Key Takeaways (4–5 sentences)

Mirizzi syndrome is a relatively rare cause of obstructive jaundice, often mimicking choledocholithiasis. The stone typically lodges in the gallbladder infundibulum or cystic duct, compressing or even eroding into the common hepatic duct. Early recognition is important because it can complicate surgery. Timely imaging, such as CT or MRCP, aids in diagnosis and helps avoid inadvertent bile duct injury during cholecystectomy.

Reference

  • Blumgart’s Surgery of the Liver, Biliary Tract and Pancreas, 7th edition
  • Chapter 16 (pp. 256), Chapter 34 (pp. 487), Chapter 42 (pp. 593)

MCQ 2 (All are true EXCEPT
)

Question

All of the following features are commonly associated with Mirizzi syndrome EXCEPT:

Answer Choices

A. An impacted gallstone in the cystic duct or gallbladder neck

B. External compression of the common hepatic duct

C. Fistula formation between the gallbladder and intestinal tract in advanced disease

D. Strong indication for laparoscopic cholecystectomy in all cases

Correct Answer: D. Strong indication for laparoscopic cholecystectomy in all cases.

Explanation

  • Why D is incorrect (and hence the correct choice in an “EXCEPT” format): In Mirizzi syndrome, a laparoscopic approach has a high risk of conversion and complications; open surgery is often recommended, especially in severe inflammation or advanced types.
  • Why A, B, C are correct:
    • (A) A stone is indeed typically impacted in the infundibulum or cystic duct.
    • (B) This leads to extrinsic compression of the common hepatic duct, causing obstructive jaundice.
    • (C) In advanced disease, a cholecystobiliary or cholecystoenteric fistula can develop.

Key Takeaways (4–5 sentences)

Mirizzi syndrome can range from simple extrinsic compression (Type I) to more complex fistulization (Type II and beyond). The presence of dense inflammation makes laparoscopic surgery technically difficult with higher complication rates. Open cholecystectomy remains the gold standard when severe inflammatory changes or complex fistulas are present. Early diagnosis is key to reducing surgical complications.

Reference

  • Blumgart’s Surgery, 7th edition, Chapters 16 & 34, “Mirizzi Syndrome,” pp. 256 & 487

MCQ 3 (Scenario-Based / Basic)

Question

A 55-year-old patient presents with obstructive jaundice, elevated alkaline phosphatase, and right upper quadrant pain. Imaging shows a gallstone lodged at the infundibulum of the gallbladder with dilatation of the intrahepatic ducts but normal distal common bile duct caliber. There are no signs of malignancy. Which diagnosis is most likely?

Answer Choices

A. Choledocholithiasis

B. Mirizzi syndrome (Type I)

C. Gallbladder cancer

D. Primary sclerosing cholangitis

Correct Answer: B. Mirizzi syndrome (Type I).

Explanation

  • Why B is correct: Extrinsic compression of the hepatic duct by a gallstone in the gallbladder neck (Type I Mirizzi) often leads to proximally dilated ducts with a normal caliber distal duct.
  • Why A is incorrect: Choledocholithiasis typically causes downstream common bile duct obstruction.
  • Why C is incorrect: Gallbladder cancer may present with an obstructive picture, but no specific imaging findings in this scenario suggest malignancy.
  • Why D is incorrect: Primary sclerosing cholangitis is a chronic inflammatory disease with a characteristic “beaded” appearance on cholangiography, unrelated to an impacted gallstone.

Key Takeaways (4–5 sentences)

Mirizzi syndrome should be suspected in patients with gallstones and obstructive jaundice but a normal distal common bile duct. Type I refers to purely extrinsic compression without fistulization into the bile duct. Differentiating Mirizzi from choledocholithiasis or malignancy is crucial because the operative approach differs. Proper imaging (e.g., CT, MRCP) improves preoperative identification, helping to avoid bile duct injuries.

Reference

  • Blumgart’s Surgery, 7th edition, Chapter 16 (p. 256), Chapter 34 (p. 487)

MCQ 4 (Interpretation / Advanced)

Question

Which of the following statements regarding the surgical approach to Mirizzi syndrome is most accurate?

Answer Choices

A. Laparoscopic cholecystectomy is always the recommended treatment, with near-zero conversion rate

B. Open cholecystectomy is generally the gold standard in complex Mirizzi syndrome

C. ERCP alone usually resolves the obstructive process permanently

D. Biliary bypass is seldom needed, even in cases of fistulization

Correct Answer: B. Open cholecystectomy is generally the gold standard in complex Mirizzi syndrome.

Explanation

  • Why B is correct: Extensive inflammation and distorted anatomy often complicate Mirizzi syndrome, making laparoscopic dissection risky. For advanced or severe cases (especially with fistulas), open cholecystectomy is safer and is considered the traditional gold standard.
  • Why A is incorrect: Laparoscopic approaches can be attempted in select early cases but show high complication/conversion rates.
  • Why C is incorrect: ERCP can help decompress and stent in some settings but does not typically correct the underlying anatomical compression or fistula.
  • Why D is incorrect: In advanced types with fistulization, a biliary-enteric reconstruction (e.g., hepaticojejunostomy) may be required if there is extensive duct involvement.

Key Takeaways (4–5 sentences)

Mirizzi syndrome can be managed surgically by partial or total cholecystectomy, depending on the extent of inflammation and any fistulization. A laparoscopic approach might be feasible in carefully selected Type I cases, but conversion rates remain high. Open surgery is safer and more definitive for advanced disease (Type II–IV). ERCP can be helpful as a bridge to surgery or for diagnosis but rarely cures the anatomical compression alone.

Reference

  • Blumgart’s Surgery, 7th edition, Chapter 34 (p. 487) & Chapter 42 (p. 593)

MCQ 5 (Critical Analysis / Advanced)

Question

In Csendes’ classification of Mirizzi syndrome (type II or higher), the defining feature is:

Answer Choices

A. Stone eroding into the entire circumference of the bile duct

B. Stone compressing but not penetrating the common hepatic duct

C. Formation of a cholecystobiliary fistula with partial bile duct erosion

D. Concomitant cholecystoenteric fistula (gallbladder to bowel)

Correct Answer: C. Formation of a cholecystobiliary fistula with partial bile duct erosion.

Explanation

  • Why C is correct: Type II Mirizzi (per Csendes) involves a fistula between gallbladder and hepatic duct, where the stone has partially eroded the duct wall. Further subtypes (II, III, IV) describe increasing circumference involvement.
  • Why A is incorrect: Complete destruction of the bile duct wall is a more advanced subtype (Type IV in Csendes’ classification).
  • Why B is incorrect: That describes Type I Mirizzi (extrinsic compression without erosion).
  • Why D is incorrect: A cholecystoenteric fistula is separate (though can coexist as Type V in the updated classification).

Key Takeaways (4–5 sentences)

Csendes’ classification refines the traditional Type I and II Mirizzi syndrome. Type I is extrinsic compression; Type II and above involve varying degrees of bile duct erosion/fistulation. Understanding these sub-classifications is important for surgical planning. As the bile duct circumference involvement progresses, more complex repairs (including potential biliary reconstruction) may be needed.

Reference

  • Blumgart’s Surgery, 7th edition, Chapter 42 (p. 593)

MCQ 6 (All are true EXCEPT
 / Advanced)

Question

All of the following technical considerations apply to managing fistulized (Type II+) Mirizzi syndrome EXCEPT:

Answer Choices

A. A partial cholecystectomy may be necessary if there is dense inflammation

B. Primary closure of the bile duct may be sufficient if the fistula opening is small

C. A Roux-en-Y hepaticojejunostomy may be required in extensive biliary destruction

D. Immediate laparoscopic common bile duct exploration is always the initial step

Correct Answer: D. Immediate laparoscopic common bile duct exploration is always the initial step.

Explanation

  • Why D is incorrect (and correct in an “EXCEPT” format): In advanced/fistulized Mirizzi, surgeons typically avoid routine laparoscopic CBD exploration initially due to severe inflammation and distorted anatomy; an open approach or other techniques (e.g., partial cholecystectomy, stent placements) may be more appropriate.
  • Why A is correct: Dense inflammation can make a total cholecystectomy hazardous; partial removal is sometimes safer.
  • Why B is correct: If the fistula into the bile duct is small, direct closure can be performed, especially if the duct is not severely damaged.
  • Why C is correct: If a large segment of the duct is destroyed, a biliary-enteric anastomosis (like hepaticojejunostomy) may be needed.

Key Takeaways (4–5 sentences)

Advanced Mirizzi syndrome can complicate surgical anatomy, especially with cholecystobiliary fistulas. Different operative strategies are needed based on the degree of ductal erosion. While laparoscopic options exist for carefully selected cases, an open approach is often safer in Type II or higher. Biliary reconstruction is reserved for significant ductal destruction, emphasizing the importance of preoperative planning and intraoperative adaptability.

Reference

  • Blumgart’s Surgery, 7th edition, Chapter 42 (p. 593)

MCQ 7 (Scenario + Problem-Solving / Advanced)

Question

A 62-year-old patient is suspected to have Mirizzi syndrome Type II with a possible cholecystobiliary fistula. An ERCP shows a partial defect where the cystic duct enters the common hepatic duct, but the exact anatomy remains unclear. The surgeon is concerned about a complex fistula and potential severe inflammation. What is the most appropriate next step in management?

Answer Choices

A. Proceed with urgent laparoscopic cholecystectomy

B. Perform open surgical exploration with possible partial cholecystectomy

C. Attempt repeated ERCP stenting to “heal” the fistula

D. Obtain no further imaging; schedule for routine laparoscopic exploration in 6 weeks

Correct Answer: B. Perform open surgical exploration with possible partial cholecystectomy.

Explanation

  • Why B is correct: In Type II Mirizzi with unclear anatomy and high suspicion of severe inflammatory changes/fistulization, open surgery provides better control, safer dissection, and the option of partial cholecystectomy or biliary reconstruction if needed.
  • Why A is incorrect: Urgent laparoscopic surgery in the setting of advanced Mirizzi carries a high risk of CBD injury and may lead to unplanned conversion.
  • Why C is incorrect: While ERCP stenting may decompress the biliary system, it rarely corrects an established fistula or ensures resolution of the stone in advanced Mirizzi.
  • Why D is incorrect: Additional imaging (e.g., CT or MRCP) is often crucial, and indefinite delay without addressing the impacted stone can worsen inflammation.

Key Takeaways (4–5 sentences)

Type II Mirizzi presents a surgical challenge because of distortion in the hepatocystic triangle and possible cholecystobiliary fistula. Definitive management often involves an open surgical approach, which can be tailored to the extent of ductal involvement. ERCP decompression can help in some cases but does not resolve complex fistulas. Thorough preoperative imaging and planning are essential to avoid inadvertent bile duct injury.

Reference

  • Blumgart’s Surgery, 7th edition, Chapter 42 (p. 593)

MCQ 8 (Image-Based / Interpretation)

Question

A hypothetical CT image is presented here, showing an enlarged gallbladder with a large stone impacted at the gallbladder neck (arrow). The common hepatic duct is dilated above the level of the stone, while the distal common bile duct appears of normal caliber. Surrounding inflammatory changes are noted near the gallbladder infundibulum.

(Space for CT image)

Based on the illustrated CT findings, which condition is most consistent with this presentation?

Answer Choices

A. Choledochal cyst

B. Mirizzi syndrome

C. Pancreatic head mass causing obstructive jaundice

D. Portal vein thrombosis

Correct Answer: B. Mirizzi syndrome.

Explanation

  • Why B is correct: A stone impacted at the gallbladder neck with proximal biliary dilation but normal distal CBD is a hallmark imaging feature of Mirizzi syndrome. The inflammatory changes at the infundibulum also support this diagnosis.
  • Why A is incorrect: A choledochal cyst would appear as a cystic dilatation of the common bile duct itself, not an impacted stone.
  • Why C is incorrect: A pancreatic head mass would typically narrow the distal CBD, and the stone in the gallbladder infundibulum wouldn’t be the cause of obstruction.
  • Why D is incorrect: Portal vein thrombosis does not directly cause extrahepatic bile duct compression and an impacted stone appearance.

Key Takeaways (4–5 sentences)

CT imaging can help distinguish Mirizzi syndrome from other causes of obstructive jaundice. Key findings include a gallstone lodged in the gallbladder neck or cystic duct, dilation of the common hepatic duct above the stone, and a normal distal duct. Accompanying inflammatory changes are common. Recognizing these features aids in proper surgical planning.

Reference

  • Blumgart’s Surgery, 7th edition, Chapter 16 (p. 256), Figures on Mirizzi syndrome

MCQ 9 (Comparison / Advanced)

Question

Which imaging technique is generally most definitive for defining a cholecystobiliary fistula in suspected Mirizzi syndrome Type II or higher?

Answer Choices

A. Endoscopic Ultrasound (EUS)

B. Magnetic Resonance Cholangiopancreatography (MRCP)

C. Plain abdominal radiograph

D. HIDA scan

Correct Answer: B. Magnetic Resonance Cholangiopancreatography (MRCP).

Explanation

  • Why B is correct: MRCP provides a noninvasive detailed view of the biliary anatomy, making it especially useful for identifying a possible fistulous tract.
  • Why A is incorrect: EUS helps visualize gallstones and wall thickness, but it is not the most definitive test for complex fistula identification.
  • Why C is incorrect: Plain X-ray might show nonspecific calcifications or air in the biliary tree but is not definitive for Mirizzi syndrome.
  • Why D is incorrect: A HIDA scan can show cystic duct leaks or partial obstruction but is less precise for defining the exact fistulous site compared to MRCP.

Key Takeaways (4–5 sentences)

For advanced Mirizzi syndrome, cross-sectional imaging is crucial to determine if a fistula has formed. MRCP excels at delineating biliary anatomy and identifying discontinuities or abnormal communications. If needed, ERCP can provide both diagnostic confirmation and therapeutic stenting, but MRCP remains the gold-standard noninvasive imaging technique for mapping complex anatomy. This information helps direct safe operative planning.

Reference

  • Blumgart’s Surgery, 7th edition, Chapter 42 (p. 593)

MCQ 10 (Scenario + Management / Advanced)

Question

A 70-year-old patient with a cholecystoenteric fistula and Type II Mirizzi syndrome experiences an acute gallstone ileus. During emergency surgery, the obstructing stone is removed via enterotomy. Intraoperatively, the gallbladder is found densely adherent to the duodenum with severe inflammation. Which of the following best describes the recommended management approach?

Answer Choices

A. One-stage procedure: remove the stone, take down the fistula, and perform definitive cholecystectomy all at once in every case

B. Two-stage approach: first relieve the intestinal obstruction, then address the fistula and gallbladder at a later operation if needed

C. Medical management only: antibiotics and observation since the stone was removed

D. ERCP and stent the duodenum to prevent further obstruction

Correct Answer: B. Two-stage approach: first relieve the intestinal obstruction, then address the fistula and gallbladder at a later operation if needed.

Explanation

  • Why B is correct: In an unstable or inflamed operative field (as with gallstone ileus plus a complicated fistula), the priority is to relieve the obstruction (enterotomy and stone extraction). Cholecystectomy and fistula takedown can be performed later if the patient is not stable enough for a prolonged procedure or if the local inflammation is prohibitive.
  • Why A is incorrect: A one-stage repair is feasible in well-selected stable patients with minimal inflammation, but not always indicated. Attempting all steps in a critically ill patient can increase morbidity.
  • Why C is incorrect: Simply removing the stone does not address the ongoing risk of recurrent bile duct problems or persistent fistula.
  • Why D is incorrect: ERCP and stenting is not the solution for a duodenal fistula with severe inflammation and gallstone ileus. The mechanical obstruction has already been addressed surgically.

Key Takeaways (4–5 sentences)

In the setting of gallstone ileus with a cholecystoenteric fistula, the immediate surgical goal is to relieve the bowel obstruction (enterotomy to extract the stone). Definitive correction of the biliary pathology (cholecystectomy and fistula repair) can be delayed if inflammation is extensive or the patient is hemodynamically compromised. This two-stage approach lowers perioperative risk. Postoperative follow-up imaging and planning remain essential to prevent future complications.

Reference

  • Blumgart’s Surgery, 7th edition, Chapter 34 (p. 487) & Chapter 42 (p. 593)

Final Note

These 10 MCQs integrate basic and advanced levels, a variety of question types (factual, scenario-based, critical analysis, “All are true EXCEPT...”), and an image-based question with space for a CT image. They draw on references from Blumgart’s Surgery of the Liver, Biliary Tract and Pancreas, 7th edition, primarily chapters 16, 34, and 42, covering Mirizzi syndrome in depth.