Hemobilia and Mirizzi Syndrome: A Rare Combination

A 64-year-old obese woman presented with sudden onset of abdominal pain and hematemesis. Physical exam was notable for tenderness in the right upper quadrant (RUQ) with a positive Murphy’s sign. Lab results showed elevated aspartate aminotransferase 291 U/L, alanine aminotransferase 231 U/L, and total bilirubin 2.3 mg/L. A RUQ ultrasound showed cholelithiasis. Total bilirubin increased to 4.3 mg/L in the next 24 hours. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a large filling defect in the proximal common bile duct (CBD), close to the takeoff of the cystic duct and indicative of Mirizzi syndrome, and blood clots extruding through the major papilla consistent with hemobilia (Figure 1 and Figure 2). Balloon catheter removal of the stones was unsuccessful due to the largest stone appearing to be within the gallbladder fossa; a biliary stent was placed for biliary drainage. Computed tomography showed a large gallstone with