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Old 09-01-2012
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Liver Mirizzi syndrome vs Choledocholithiasis

A patient on the waiting list for cholecystectomy is admitted with deep jaundice and a mild colicky right upper quadrant pain. He reports an alteration in the colour of urine and stool but does not report fever or rigors. There are no signs of tenderness on palpation. What is the MOST likely diagnosis?
a) Acute cholecystitis
b) Biliary colic
c) Choledocholithiasis
d) Cholelithiasis
e) Mirizzi's syndrome

By the way, does anyone know how to differentiate Mirizzi syndrome from Choledocholitiasis clinically ?
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Default e) Mirizzi's syndrome

Thanks for question.
Ya, mirizzi's syndrome is just like cholelithiasis and Choledocholithiasis. The only difference is instead of direct compression of cystic duct or CBD. Mirizzi's syndrome causes indirect compression of these duct.

So i think "no signs of tenderness on palpation" is key to answer here. Ya still if "Mirizzi syndrome" would not be option. Then cholelithiasis or choledocholithiasis would be the answer.

I think ERCP would be the best way to differentiate mirizzi from others. Anyways atlast when we have to do cholecystictomy. Don't making a sperate diagnosis matters? May be if there is "choledocholedocal fistula" can be complication for leproscopic surgery.
Mirizzi syndrome vs Choledocholithiasis-mirizzi.gif
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Default C..choledocholithiasis?

Cccc.....since there is no charcots triad.
i hate all these many frustrating names pointing to one gallblader dx
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Wink mirrizi

i would go with mirrizi since all of the other options have pain
Acute cholecystitis (pain ), Biliary colic (colicky pain ), Choledocholithiasis (charcot's triad RUQ pain ) and the same goes for Cholelithiasis

so only mirrizi could come with pain or without .......so it is the only possible answer
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e) mirizzi syndrome is the answer

mirizzi syndrome may not be presented with consistent features
it's most commonly caused by gall stone impacted at hartmann's pouch and fistula formation is it's complication
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Sadly mirrizi syndrome isn't mentioned in FA

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Default The Answer

The official answer is c) Choledocholithiasis.
Charcot triad does not apply here, as they are the criteria for ascending cholangitis secondary to an untreated choledocholithiasis.
The clinical presentations of Mirizzi and Choledocholithiasis are largely indistinguishable by physical examinations. Since the question was asking the MOST LIKELY cause, therefore choledocholithiasis is the choice (because Mirizzi is a rare condition --> not most likely option)
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I cannot picture how the stones in cystic duct or Hartmann's pouch can compress the common bile duct or even facilitate fistula formation? There is part of duodenum seperating gallbladder and common bile duct. In this way, will the inflammation of gallbladder or cystic duct penetrate intestinal wall?

Please help me clarify this point. Many thanks!
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Quote:
Originally Posted by HaipengWang View Post
The official answer is c) Choledocholithiasis.
Charcot triad does not apply here, as they are the criteria for ascending cholangitis secondary to an untreated choledocholithiasis.
The clinical presentations of Mirizzi and Choledocholithiasis are largely indistinguishable by physical examinations. Since the question was asking the MOST LIKELY cause, therefore choledocholithiasis is the choice (because Mirizzi is a rare condition --> not most likely option)
So that means patient should have "Charcot's triad" to have cholecystectomy?
Can you briefly explain how not having charcot triad is related to diagnosis?
Thanks
Meanwhile, to have charcot triad person should have (Jaundice, RUQ pain and fever). This person have 2 above mentioned symptoms and noting mentioned about fever. So we assume that this person don't have fever?
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this question isn't from kaplan nor uw so i am sticking with the fact that it is low yield and have mental relief. :-)

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see the pic . it tells you how it compresses the common bile duct
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Mirizzi syndrome vs Choledocholithiasis-screen-shot-2012-09-02-1.48.24-pm.jpg  
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Quote:
Originally Posted by belindalimm View Post
I cannot picture how the stones in cystic duct or Hartmann's pouch can compress the common bile duct or even facilitate fistula formation? There is part of duodenum seperating gallbladder and common bile duct. In this way, will the inflammation of gallbladder or cystic duct penetrate intestinal wall?

Please help me clarify this point. Many thanks!
I have attached a picture in my above post. You can have a look.
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Default

Most common things occur commonly guys..
Every one choose mirizzi because it sounded mirizziI have never heard that name before
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Default In response to koolkiller88's question

RUQ pain + jaundice + fever (Charcot triad) = ascending cholangitis
RUQ pain + jaundice + afebrile = choledocholithiasis (90%) or Mirizzi (<1%)
Also, we ALWAYS ALWAYS offer cholecystectomy as soon as gallstones start to cause pain (with or without fever), because once the pain starts the symptoms always progressively become worse in time. Remember gallstone formation is a problem with either the gallbladder muscle (slow motility) or gallbladder mucusa (bile concentration ability), not a problem to do with the serum cholesterol levels. Therefore even if you are able to remove all the stones from the gallbladder, in time new stones will form. ... BMJ recommend cholecystectomy for all symptomatic gallstone px.
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  #15  
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Default What does a gallbladder do?

Answer: Nothing, we dont really need it anymore! Gallbladder evolved way beyond the prehistoric times – when our ancestors lived on irregular food supplies so kept a reserve of bile in gallbladder for times of big binges of fat.
but nowadays we don’t really need it because we constantly have access to fat
Once stones are present in gallbladder, it doesn’t work anyway! (so take it out!!) If remove just the stones, it will produce more stones again because genetic factors dominate the process of gallstone formation (remove the GB!)
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Quote:
Originally Posted by HaipengWang View Post
Answer: Nothing, we dont really need it anymore! Gallbladder evolved way beyond the prehistoric times – when our ancestors lived on irregular food supplies so kept a reserve of bile in gallbladder for times of big binges of fat.
but nowadays we don’t really need it because we constantly have access to fat
Once stones are present in gallbladder, it doesn’t work anyway! (so take it out!!) If remove just the stones, it will produce more stones again because genetic factors dominate the process of gallstone formation (remove the GB!)
what you wrote was quite funny...yes ,i also think there won't be a problem if gall bladder is removed......but we can get more loose stools after it's removal

http://drsastry.arachnis.com/nogall.htm
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what you wrote was quite funny...yes ,i also think there won't be a problem if gall bladder is removed......but we can get more loose stools after it's removal

http://drsastry.arachnis.com/nogall.htm
Ya, and with US oriented Burger's and sandwiches diet. I think my gall bladder would have to do lot of work sometimes.
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Quote:
Originally Posted by koolkiller88 View Post
Thanks for question.
Ya, mirizzi's syndrome is just like cholelithiasis and Choledocholithiasis. The only difference is instead of direct compression of cystic duct or CBD. Mirizzi's syndrome causes indirect compression of these duct.

So i think "no signs of tenderness on palpation" is key to answer here. Ya still if "Mirizzi syndrome" would not be option. Then cholelithiasis or choledocholithiasis would be the answer.

I think ERCP would be the best way to differentiate mirizzi from others. Anyways atlast when we have to do cholecystictomy. Don't making a sperate diagnosis matters? May be if there is "choledocholedocal fistula" can be complication for leproscopic surgery.
Attachment 2794
Hi koolkiller88,

Thanks for your attaching picture in your post.

The picture shows gallbladder are adjacent to common bile duct, in this way it is not hard to imagine the mechanism of common bike duct compression by gallbladder stones and fistula formation. But a portion of duodenum lies between them, so it is not easy for gallbladder stone forming to compress the common bile duct.

Maybe I'm wrong, but I really want to clear it out. Thanks for discussing with me!
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Quote:
Originally Posted by koolkiller88 View Post
I have attached a picture in my above post. You can have a look.
Hi koolkiller88,

I think I'm getting the idea of the way that gallbladder stones compress the common bile duct. I was previously somewhat wrong about the relative positions among gallbladder, common bile duct and duodenum. Thanks for your explanation picture!
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Ya, and with US oriented Burger's and sandwiches diet. I think my gall bladder would have to do lot of work sometimes.
Exactly ! That is the exact reason that you should let go of your gallbladder (when it causes pain). So that your body will not absorb all the excess fat from McDonald's and Burger Kings. A loose stool is a small price to pay for a healthier and slimmer body. [An Australian study by Dr Hamilton & Dr Goodwin (2011) on a 5-year-follow-up of 2367 px had cholecystectomy. These px have much optimal serum cholesterol levels, much lower BMI (on average loss of 8.6 kg), and better overall health, compared to the age-sex-adjusted control group]
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Exactly ! That is the exact reason that you should let go of your gallbladder (when it causes pain). So that your body will not absorb all the excess fat from McDonald's and Burger Kings. A loose stool is a small price to pay for a healthier and slimmer body. [An Australian study by Dr Hamilton & Dr Goodwin (2011) on a 5-year-follow-up of 2367 px had cholecystectomy. These px have much optimal serum cholesterol levels, much lower BMI (on average loss of 8.6 kg), and better overall health, compared to the age-sex-adjusted control group]
Hahaha..but just imagine. You are out for a date in restaurant and after having a dinner you have to say "sorry dear i have to poo". Don't it sounds....Date screwed
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Originally Posted by belindalimm View Post
Hi koolkiller88,

Thanks for your attaching picture in your post.

The picture shows gallbladder are adjacent to common bile duct, in this way it is not hard to imagine the mechanism of common bike duct compression by gallbladder stones and fistula formation. But a portion of duodenum lies between them, so it is not easy for gallbladder stone forming to compress the common bile duct.

Maybe I'm wrong, but I really want to clear it out. Thanks for discussing with me!
Ya i think you are right somewhat but you know in gallbladder and cystic duct place we have lot of anatomical variants and over all this mirizzi syndrome is in <1% of cases that means gall bladder and CBD or cystic duct fistula is not common finding anyways.
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