Csendes classification of Mirizzi syndrome

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Classifies Mirizzi syndrome by extrinsic bile-duct compression versus circumferential loss from a cholecystobiliary fistula, then adds cholecystoenteric fistula and gallstone ileus as a type V overlay.

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Escala de categorias

I II III IV Va Vb

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Procedência e vigência

Órgão emissor: Csendes et al.
Versão: 1989 + 2008 type V extension
Ano: 1989
Família: léxico
Tipo de lógica: flat
Modalidade: MRI, CT, US
Fonte primária: Mirizzi syndrome and cholecystobiliary fistula: a unifying classification · doi:10.1002/bjs.1800761110
Última verificação: 2026-07-24
Última checagem: 2026-07-24

Lógica de decisão

Forma estruturada (flat). Uma futura calculadora a lê; as categorias abaixo são a superfície legível.

Return a base type I-IV plus a Va/Vb overlay whenever type V applies. Keep preoperative suspicion separate from definitive wall-loss classification and use the result to communicate anatomy, not to order an operation.

Mostrar a lógica estruturada (JSON)

{
  "categories": [
    {
      "outcome_code": "I",
      "mechanism": "extrinsic_bile_duct_compression",
      "cholecystobiliary_fistula": "absent",
      "bile_duct_wall_circumference_eroded": "none"
    },
    {
      "outcome_code": "II",
      "mechanism": "cholecystobiliary_fistula",
      "bile_duct_wall_circumference_eroded": "less_than_or_up_to_one_third"
    },
    {
      "outcome_code": "III",
      "mechanism": "cholecystobiliary_fistula",
      "bile_duct_wall_circumference_eroded": "more_than_one_third_and_up_to_two_thirds"
    },
    {
      "outcome_code": "IV",
      "mechanism": "cholecystobiliary_fistula",
      "bile_duct_wall_circumference_eroded": "complete",
      "anatomic_result": "complete_duct_wall_destruction_and_fusion_with_gallbladder"
    },
    {
      "outcome_code": "Va",
      "overlay": "any_underlying_type_I_to_IV_plus_cholecystoenteric_fistula",
      "gallstone_ileus": "absent"
    },
    {
      "outcome_code": "Vb",
      "overlay": "any_underlying_type_I_to_IV_plus_cholecystoenteric_fistula",
      "gallstone_ileus": "present"
    }
  ],
  "applicability": {
    "use_for": "Anatomic description and procedural planning when an impacted gallstone causes extrinsic hepatic-duct or bile-duct compression, cholecystobiliary fistula, or a related cholecystoenteric fistula.",
    "classification_unit": "one_Mirizzi_anatomic_complex_at_the_time_of_assessment",
    "required_inputs": [
      "impacted_stone_location",
      "extrinsic_duct_compression",
      "cholecystobiliary_fistula_presence",
      "estimated_fraction_of_duct_wall_loss",
      "cholecystoenteric_fistula_presence",
      "gallstone_ileus_presence"
    ],
    "outside_scope": [
      "malignant_hilar_obstruction",
      "isolated_choledocholithiasis_without_Mirizzi_mechanism",
      "postoperative_bile_duct_injury_classification",
      "treatment_selection_without_hepatobiliary_expertise"
    ]
  },
  "core_classification_algorithm": [
    {
      "if": "external_compression_without_cholecystobiliary_fistula",
      "output_code": "I"
    },
    {
      "if": "cholecystobiliary_fistula_with_wall_loss_not_exceeding_one_third",
      "output_code": "II"
    },
    {
      "if": "cholecystobiliary_fistula_with_wall_loss_more_than_one_third_and_not_exceeding_two_thirds",
      "output_code": "III"
    },
    {
      "if": "complete_circumferential_duct_wall_destruction",
      "output_code": "IV"
    }
  ],
  "type_V_overlay_algorithm": {
    "prerequisite": "A cholecystoenteric fistula coexists with an underlying Csendes I, II, III, or IV lesion.",
    "without_bowel_obstruction_from_a_gallstone": "Va",
    "with_gallstone_ileus": "Vb",
    "mandatory_companion_output": "Always report the underlying I-IV anatomy when it can be established; Va or Vb alone discards the bile-duct-wall information needed for planning.",
    "nonordinal_rule": "Type V is an overlay, not a simple severity step after IV. Va and Vb describe enteric fistula and ileus status while the underlying I-IV type describes the biliary defect."
  },
  "preoperative_assessment": {
    "ultrasound": [
      "impacted_infundibular_or_cystic_duct_stone",
      "intrahepatic_or_common_hepatic_duct_dilatation",
      "gallbladder_contraction_or_inflammation"
    ],
    "MRCP_or_CT": [
      "level_and_length_of_obstruction",
      "stone_and_fistula_anatomy",
      "biliary_confluence",
      "adjacent_duodenum_stomach_or_colon",
      "bowel_obstruction_and_ectopic_stone"
    ],
    "ERCP_or_cholangiography_when_performed": [
      "duct_lumen_and_filling_defect",
      "stricture_or_fistula",
      "distal_duct_patency",
      "decompression_or_stent_context"
    ],
    "certainty_rule": "Preoperative imaging can suggest the class, but exact circumferential wall loss is often established during cholangiography or surgery. Label an imaging-only class as suspected when the fistula or wall fraction is not directly demonstrated."
  },
  "operative_planning_implications_from_primary_series": {
    "I": "The original series treated external compression without a duct-wall fistula differently from wall-loss lesions; anatomy must be clarified before dissection.",
    "II": "A limited wall defect may permit repair or choledochoplasty in expert hands; the code does not mandate a single technique.",
    "III": "The original series advised against simple fistula suture and favored choledochoplasty for the larger wall defect.",
    "IV": "The original series preferred bilioenteric reconstruction for complete duct-wall destruction.",
    "Va": "Plan for both the underlying biliary lesion and closure or management of the involved enteric organ; preserve the base I-IV type.",
    "Vb": "Gallstone ileus adds bowel-obstruction management. The 2008 validation supports a staged strategy in selected patients, but timing and procedures remain individualized.",
    "safety_rule": "These are anatomic planning implications from the source cohorts, not an autonomous operative prescription; current approach depends on physiology, inflammation, malignancy exclusion, local expertise and intraoperative anatomy."
  },
  "risk_model": {
    "common_risks": [
      "distorted_Calot_triangle_anatomy",
      "bile_duct_injury",
      "vascular_or_adjacent_organ_injury",
      "residual_stone",
      "biliary_leak_or_stricture",
      "infection"
    ],
    "severity_trend": "In the original 1989 cohort, operative morbidity and mortality increased with the extent of the cholecystobiliary lesion.",
    "type_V_addition": "Cholecystoenteric fistula adds adjacent-organ involvement; Vb additionally identifies mechanical bowel obstruction from a gallstone.",
    "nonquantitative_rule": "The class does not provide a validated patient-specific complication percentage or mortality calculator."
  },
  "differential_and_safety_checks": [
    "Exclude cholangiocarcinoma or gallbladder malignancy when the obstruction, wall thickening, mass, nodes or clinical course are atypical.",
    "Do not call Type I from duct dilatation alone; demonstrate or strongly support the impacted-stone compression mechanism.",
    "Do not estimate a II-versus-III wall fraction from luminal narrowing alone when the fistula is not directly established.",
    "Do not use Bismuth-Corlette, Strasberg or bile-leak injury categories as substitutes for the Csendes Mirizzi anatomy."
  ],
  "output_contract": [
    "suspected_or_confirmed_Mirizzi_mechanism",
    "impacted_stone_location",
    "level_of_biliary_obstruction_and_upstream_dilatation",
    "cholecystobiliary_fistula_and_fraction_of_wall_loss",
    "base_Csendes_code_I_to_IV",
    "cholecystoenteric_fistula_and_involved_organ",
    "Va_or_Vb_overlay_with_gallstone_ileus_status",
    "certainty_and_modality",
    "malignancy_or_alternative_diagnosis_warning",
    "hepatobiliary_planning_flag_without_autonomous_surgery"
  ],
  "missing_input_behavior": [
    "If a fistula is suspected but circumferential wall loss is unknown, do not guess II, III or IV; report suspected cholecystobiliary fistula and request definitive delineation.",
    "If a cholecystoenteric fistula is present but bowel-obstruction or ectopic-stone status is unknown, do not choose Va or Vb.",
    "If Va or Vb is assigned but the underlying I-IV anatomy is unresolved, state that base type is indeterminate rather than treating V as a complete description.",
    "If malignancy remains a credible better explanation, do not finalize Mirizzi type as the sole diagnosis."
  ],
  "interpretation_limits": [
    "Csendes is an anatomic surgical classification, not a radiology-only certainty score, treatment mandate or calibrated prognosis.",
    "The I-IV thresholds refer to circumference of bile-duct wall loss, not longitudinal fistula length or percentage luminal stenosis."
  ],
  "source_locator": "Csendes et al., Br J Surg 1989;76:1139-1143, PMID 2597969, DOI 10.1002/bjs.1800761110, abstract and original type-specific operative discussion; Beltran, Csendes and Cruces, World J Surg 2008;32:2237-2243, PMID 18587614, DOI 10.1007/s00268-008-9660-3, Table 1, Results and Discussion for type V, underlying anatomy, complications and gallstone-ileus strategy."
}

Categorias num relance

Cat.	Significado	Conduta	Risco	Fonte
I	Type I, extrinsic compression without fistula External compression of the common hepatic duct or common bile duct by an impacted gallstone at the gallbladder infundibulum, neck, or cystic duct, without a cholecystobiliary fistula or bile-duct-wall loss.	Flag distorted hilar and Calot-triangle anatomy before dissection and define the duct and stone relationship. The original series reported cholecystectomy with duct exploration or drainage as effective, but the type is a planning descriptor and does not prescribe a current operation.	Even without a duct-wall fistula, inflammation and distorted anatomy create bile-duct and vascular injury risk. Type I does not provide a calibrated complication probability and should not be inferred from upstream dilatation alone.	okfonte Csendes et al. 1989, PMID 2597969, abstract: Type I external compression; original operative discussion for Type I and increasing morbidity with lesion severity.
II	Type II, cholecystobiliary fistula up to one-third wall loss Cholecystobiliary fistula produced by gallstone erosion with a limited bile-duct-wall defect involving up to approximately one-third of the duct circumference.	Report the fistula and estimated wall fraction because a limited defect may permit repair or choledochoplasty in expert hands. The original series described absorbable suture or choledochoplasty using gallbladder remnant; current technique remains individualized.	A true duct-wall defect increases the complexity and risk of bile leak, stricture and iatrogenic duct injury compared with external compression alone. The code supplies no patient-specific event percentage.	okfonte Csendes et al. 1989, PMID 2597969, abstract: Type II fistula with less than one-third wall erosion and original repair options; Beltran et al. 2008 restatement uses one-third.
III	Type III, fistula up to two-thirds wall loss Cholecystobiliary fistula with a larger bile-duct-wall defect extending beyond the Type II range and involving up to approximately two-thirds of the duct circumference.	Communicate the large wall defect for hepatobiliary reconstruction planning. The original series advised against simple fistula suture and recommended choledochoplasty; the exact contemporary operation depends on tissue quality and anatomy.	The larger wall defect implies more difficult reconstruction and greater operative morbidity than limited erosion in the original severity trend, but Type III is not a calibrated outcome score.	okfonte Csendes et al. 1989, PMID 2597969, abstract: Type III fistula up to two-thirds of duct circumference, simple suture not indicated, choledochoplasty recommended.
IV	Type IV, complete bile-duct-wall destruction Cholecystobiliary fistula with complete circumferential destruction of the bile-duct wall, with the gallbladder and duct fused into a single inflammatory structure.	Flag complete wall loss for complex hepatobiliary reconstruction. The original series preferred a bilioenteric anastomosis, but imaging or type alone must not order a procedure or define the reconstruction.	Complete wall destruction is the most extensive I-IV biliary defect and was associated with the highest end of the original increasing morbidity and mortality trend. No individual risk percentage is encoded by the class.	okfonte Csendes et al. 1989, PMID 2597969, abstract: Type IV complete duct destruction, bilioenteric anastomosis preferred, operative morbidity and mortality increasing with lesion severity.
Va	Type Va, cholecystoenteric fistula without gallstone ileus Any underlying Csendes Type I-IV Mirizzi lesion with a coexisting cholecystoenteric fistula and no gallstone ileus. The involved organ can be duodenum, stomach, colon, or another directly fistulized viscus.	Report and plan for both components: the underlying I-IV biliary defect and the enteric fistula or involved organ. The 2008 series repaired enteric fistulas in the context of varied base-type operations; Va alone does not select a single procedure.	Va adds adjacent-organ involvement, difficult inflammatory planes and risk of enteric, biliary and vascular injury. The 2008 cohort showed complications rising with biliary severity, but Va is not a patient-specific risk percentage and remains incomplete without the base I-IV type.	okfonte Beltran, Csendes and Cruces 2008, DOI 10.1007/s00268-008-9660-3, Table 1 (Type V any base type plus cholecystoenteric fistula; Va without gallstone ileus), Results on involved organs and procedures, Tables 5-6 and Discussion.
Vb	Type Vb, cholecystoenteric fistula with gallstone ileus Any underlying Csendes Type I-IV Mirizzi lesion with a cholecystoenteric fistula and gallstone ileus, meaning mechanical bowel obstruction caused by a gallstone that entered through the fistula.	Treat bowel obstruction as an urgent separate problem while preserving the underlying biliary type. The 2008 validation supports a staged strategy in selected patients and often used enterolithotomy first, but physiology, obstruction site, fistula anatomy and specialist judgment determine timing and procedures.	Vb adds acute mechanical bowel obstruction to the biliary and enteric-fistula hazards. It is not simply one ordinal step above Va and does not encode an individual mortality, recurrence or operative-complication probability.	okfonte Beltran, Csendes and Cruces 2008, DOI 10.1007/s00268-008-9660-3, Table 1 (Vb with gallstone ileus), Results describing enterolithotomy and Discussion supporting two-stage surgery in selected gallstone-ileus patients.

Referências cruzadas

fronteira compartilhadaBismuth-Corlette. Modified Bismuth-Corlette classification of perihilar cholangiocarcinomaBoth describe obstruction at the biliary confluence: Mirizzi from extrinsic stone impaction and fistula, Bismuth-Corlette from hilar cholangiocarcinoma.

Histórico de versões

Data	Evento	Detalhe	Situação
2008-10-01	revised	Beltran and Csendes validated type V as any underlying I-IV Mirizzi lesion with a cholecystoenteric fistula, divided into Va without and Vb with gallstone ileus. evidência	confirmado
2008-01-01	revised	Csendes classification extended with type V (cholecystoenteric fistula; Va and Vb) by Beltran and Csendes.	confirmado

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