title: Mirizzi syndrome with a fistula at the confluence of the hepatic ducts.
abstract: BACKGROUND
  A rare case of Mirizzi syndrome with atypical presentation is reported.
  
  
  METHODS
  An 81-year-old woman with a known history of cholelithiasis presented with epigastric discomfort and indigestion. Imaging investigations revealed Mirizzi syndrome, while a cholecystobiliary fistula at the junction of the hepatic ducts was recognized intraoperatively and treated successfully with cholecystectomy and Roux-en-Y hepaticojejunostomy. During two years' follow-up the patient remains free of biliary symptoms.
  
  
  CONCLUSIONS
  Diagnosis of Mirizzi syndrome requires a high degree of clinical suspicion, especially in cases without obstructive jaundice. A fistula at the level of the confluence of the hepatic ducts is a rare topographic variant of the syndrome that may need a totally different surgical approach.
authors.affiliation: 4th Surgical Department, Aristotle University of Thessaloniki, G. Papanikolaou General Hospital, Exohi, Thessaloniki, Greece. Ctsalis@med.auth.gr
authors.forename: Kostas G
authors.initials: KG
authors.lastname: Tsalis
authors.forename: Emmanouil
authors.initials: E
authors.lastname: Zacharakis
authors.forename: Ioanna E
authors.initials: IE
authors.lastname: Kirou
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Sapidis
authors.forename: Ioannis
authors.initials: I
authors.lastname: Vagios
authors.forename: Stavros
authors.initials: S
authors.lastname: Kalfadis
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Betsis
mesh_terms: D000015:Abnormalities, Multiple / Q000000981:diagnostic imaging / Q000473:pathology*; D000368:Aged; D000713:Anastomosis, Roux-en-Y; D049448:Cholangiopancreatography, Magnetic Resonance; D002769:Cholelithiasis / Q000150:complications / Q000000981:diagnostic imaging; D005260:Female; D005402:Fistula / Q000150:complications* / Q000000981:diagnostic imaging / Q000473:pathology; D042882:Gallstones / Q000150:complications / Q000000981:diagnostic imaging; D006500:Hepatic Duct, Common / Q000000981:diagnostic imaging / Q000473:pathology*; D006801:Humans; D013577:Syndrome; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography