An Elderly Woman with Abdominal Pain: Mirizzi Syndrome.

BACKGROUND Mirizzi syndrome is an uncommon but clinically important complication of gallbladder disease that occurs when there is extrinsic compression of the common hepatic duct from gallstones within the cystic duct or from within the gallbladder itself. Obstructive jaundice and cholangitis may ensue. In severe cases, bile duct erosion or gallbladder rupture occur. CASE REPORT A demented 80-year-old woman presented to the Emergency Department (ED) with fever and right upper-quadrant abdominal guarding and tenderness. Computed tomography of the abdomen revealed a markedly dilated and thickened gallbladder with hyperdensity in the region of the gallbladder neck. The mass effect of these gallstones caused central intrahepatic biliary ductal dilatation from extrinsic compression of the extrahepatic biliary duct, consistent with Mirizzi syndrome. Additionally, there were 2 areas of focal rupture of the gallbladder wall. General Surgery recommended non-operative management and temporizing the patient with a cholecystostomy tube. She remained in the hospital on IV antibiotics and discharged to follow-up as an outpatient with General Surgery. CONCLUSIONS Significant morbidity and mortality can be associated with the disease states of Mirizzi syndrome, and it is imperative for the ED physician to promptly recognize and treat such clinical entities. In general, treatment requires a multidisciplinary approach, using the history and physical examination to guide appropriate consultation with General Surgery, Gastroenterology, or Interventional Radiology. The prognosis of Mirizzi syndrome is related to the degree of concomitant complications. Aggressive treatment is appropriate for most patients, with surgical intervention being individualized based on the stage and severity of the disease.

Splenic torsion: a rare cause of abdominal pain.

Splenic torsion is an exceedingly rare but clinically important disease process that should be recognised promptly by the treating physician. In this condition, there is twisting of the spleen along its vascular pedicle, subsequently leading to abdominal pain in the setting of organ ischaemia. Vascular thrombosis and splenic infarction may ensue. Torsion has been described in cases of a known wandering spleen. Abnormal development of the splenic suspensory ligaments may predispose a patient to a wandering spleen. Treatment of splenic torsion is typically surgical, with goals of preservation of the spleen if possible.We present a case of a young woman who presented with left-sided chest and abdominal pain and was found to have splenic torsion with complete splenic infarction. Surgical intervention was required, and splenectomy was performed. In this case presentation, we outline the multidisciplinary approach needed to care for the patient with this rare condition.