0:00

Okay, so Mirizzi syndrome, this is next

0:03

level, but that's why you're here.

0:05

Mastering our profession is really learning the

0:07

oddities that will be helpful clinically, which

0:09

really establish dominance in our profession and

0:11

allow us to make those diagnoses that are hard.

0:14

That's what we're in it for.

0:14

We're trying to do the hard things,

0:16

not the easy, um, parts of radiology.

0:18

So I really wanted to bring this case

0:20

in because Mirizzi syndrome's a problem.

0:23

It is a difficult clinical diagnosis.

0:26

It's when you have this

0:27

stone as in this diagram, either, uh, within

0:30

the cystic duct itself or in the neck,

0:32

compressing the hepatic ducts, resulting

0:34

in intrahepatic biliary ductal dilatation.

0:36

Not only is this something that may cause

0:38

jaundice for your patients or other problems.

0:41

This can be a surgical dilemma.

0:43

These are dangerous.

0:45

They can cause fistulas to the common bile duct.

0:48

It can be a really high-level surgery.

0:49

There can be a lot of adhesions, a lot

0:52

of difficulties. Um, in our hospital,

0:54

you want the OG surgeon in these cases.

0:56

This is one of our high-level biliary surgeons.

0:58

So if a patient has Mirizzi Syndrome, they're not

1:01

goint to just send this to the acute trauma care team.

1:03

This is goint to go to somebody who's

1:05

specifically hepatobiliary trained,

1:08

because of all those adhesions.

1:09

If you tear the common bile duct, and let's be

1:11

clear, the common bile duct, it's not that strong.

1:15

So if you rip and tear that and you

1:17

have to have some kind of anastomosis,

1:19

you want the proper surgeon involved.

1:20

So this is done

1:22

very delicately at our institution, and this diagnosis

1:26

is something that we don't wanna miss for our patients.

1:29

Here's another case.

1:30

I'm just goint to show you another case just so that

1:32

you are aware of this entity, so, you know,

1:34

to heighten the level of acuity to your clinicians.

1:37

Again, Mirizzi syndrome.

1:39

Um, these are all named after old dead

1:40

white guys, so we always call it the DWG.

1:43

And Mirizzi syndrome is when you have this echogenic

1:45

obstructing stone at the porta hepatis causing

1:48

intrahepatic biliary ductal dilatation.

1:51

Here you can see that those ducts have

1:52

those echogenic surroundings and are not,

1:56

um, showing blood flow on the image here.

1:59

Beautiful Mirizzi syndrome.

2:00

Okay, let's side quest, side quest.

2:02

Permission to side quest.

2:04

Alright, dilated intrahepatic ducts.

2:06

Here's a patient who's normal.

2:07

You don't see the ducts at all, and in a

2:09

normal patient, you won't see the bile ducts.

2:11

Here is a patient who has mildly dilated,

2:13

um, bile ducts and you can see that they're

2:15

little circles on the side of the portal

2:17

veins within the parenchyma of the liver.

2:19

66 00:02:19,840 --> 00:02:22,900 Even a little bit more impressive in the left lobe here.

2:23

This is a patient who has even more dramatic

2:25

just 'cause I like to show you the drama.

2:27

Intrahepatic biliary ductal dilatation.

2:29

Here you can see the portal vein

2:30

with that just tube of bile.

2:32

Very, very dilated.

2:33

You can imagine that this patient is likely very

2:36

jaundiced, may have presented with itching or the like.

2:39

The bile ducts in the portal triad are

2:42

adjacent to the portal veins, and there can

2:44

be the little tiny hepatic artery as well.

2:46

So this is the normal findings of the portal

2:49

triads with the hepatic veins centrally,

2:53

then draining the liver into the heart.

2:55

So,

2:56

the portal triad has a lot going on, right?

2:58

Like that's, that's actually a lot going on with

3:00

the bile duct, the vein, and the artery as well.

3:04

And also in this space, there's

3:05

a lot of potential space.

3:06

There are lymphatics and there are other

3:08

soft tissue, uh, structures as well.

3:10

Some of that connective tissue.

3:12

So this is a space that has a lot of

3:15

propensity for, um, developing oddities,

3:18

one might say. Here's a patient who

3:20

comes in with right upper quadrant pain,

3:21

but they look a little bit different.

3:23

Do we say this is dilated bile ducts?

3:25

Look at this. This is not a tube on

3:27

one side of the portal vein.

3:29

Instead, these are small, low-attenuation

3:32

fluid halos around the portal vein.

3:35

Here again, we have a fluid

3:36

halo around the portal vein.

3:38

As we come down, we even have some

3:39

fluid in the retroperitoneum here.

3:42

Notice that this gallbladder, it is so thickened.

3:44

Look how thick that wall is.

3:46

This is the mucosa.

3:47

This is the gallbladder wall.

3:49

So this is a patient who has extreme

3:51

gallbladder wall thickening and, um, a lot

3:54

of fluid within the periportal regions.

3:56

But unlike a patient with

3:58

dilated bile ducts,

4:00

this is periportal edema, and this is an

4:02

entity to be very knowledgeable about because

4:04

you will see it in a lot of your patients.

4:06

Periportal edema is just basically fluid that

4:09

has accumulated in that periportal region,

4:12

in those portal triads. It's usually described as having

4:15

halos, being halos of edema, and it's nonspecific.

4:18

You can get periportal edema if

4:20

you were over-fluid hydrated,

4:23

if you have hepatitis, if you have

4:25

right-sided

4:26

heart failure, which is a really common reason,

4:28

just because there's buildup of fluid in the liver.

4:31

Anything where you have too much fluid, and I

4:33

like to say that the gallbladder wall is usually

4:35

very thick, almost too thick to be infected,

4:38

and the gallbladder is usually not distended

4:40

like you would see in acute cholecystitis.

4:42

So this is another entity that frequently kind of

4:45

gives you a little bit of confusion in the setting

4:47

of a patient who has right upper quadrant pain; they

4:49

can come in with right upper quadrant pain because

4:52

even in the setting of congestive hepatopathy from

4:55

right-sided heart failure,

4:56

patients will feel discomfort from

4:58

that pressure on their liver capsule.

5:01

So be aware of periportal edema and how it looks

5:04

different than intrahepatic biliary ductal dilatation.