Mirizzi syndrome associated with hepatic artery pseudoaneurysm: a case report

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 [1] 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 [6]. 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.A 54-year-old Caucasian man presented with a 4-month history of pain in the right hypochondrium after eating, weight loss and obstructive jaundice. On examination, the patient had a tender mass in the right upper quadrant of his abdomen. Biochemical tests showed changes consistent with obstructive jaundice (bilirubin 76 μmol/litre, alkaline phosphatase 653 U/litre, alanine aminotransferase 281 U/litre, gamma glutamyl transferase (γGT) 1792 U/litre). An abdominal ultrasound scan (USS) showed gallstones in a thick-walled gallbladder and intrahepatic duct dilatation, but no common bile duct (CBD) stones or impacted stone in Hartmann's pouch. Magnetic resonance cholangiopancreatography (MRCP) showed dilatation of the intrahepatic d