Search StatPearls

Tools](/content/account/POCFreeTrialCheck ""/index.html)

Mirizzi Syndrome

Author: [Mark W. Jones](/content/point-of-care/25184#/ ""/index.html)Editor: [Troy Ferguson](/content/point-of-care/25184#/ ""/index.html)Updated: 4/24/2023 2:13:46 PM

Introduction

Mirizzi syndrome is a rare condition caused by the obstruction of the common bile duct or common hepatic duct by external compression from multiple impacted gallstones or a single large impacted gallstone in Hartman's pouch. Presenting symptoms are similar to cholecystitis but may be confused with other obstructing conditions such as common bile duct stones and ascending cholangitis due to the presence of jaundice. Preoperative diagnosis is often difficult and usually missed. This syndrome is named after the Argentinean surgeon Pablo Luis Mirizzi. He was born in 1893 in Cordoba, Argentina. Mirizzi graduated from the Medical Sciences School at the National University of Cordoba in 1915. His most well-known contribution to surgery is having performed the first intraoperative cholangiogram in 1931. The first published paper describing the syndrome which bears his name today was in 1940. [[1]](/content/point-of-care/25184#ref_28819467 ""/index.html)

Etiology

Register For Free And Read The Full Article

Get the answers you need instantly with the StatPearls Clinical Decision Support tool. StatPearls spent the last decade developing the largest and most updated Point-of Care resource ever developed. Earn CME/CE by searching and reading articles.

Search engine and full access to all medical articles
10 free questions in your specialty
Free CME/CE Activities
Free daily question in your email
Save favorite articles to your dashboard
Emails offering discounts

Select ProfessionPracticing PhysicianPhysician AssociatePharmacistRegistered NurseNurse Practitioner/ Advanced Practice Registered NurseLicensed Practical Nurse/ Licensed Vocational NurseMedical, Dental, Podiatry, and Optometry StudentsNursing StudentAllied HealthSocial WorkerDentistDietitianOther

Select Profession

Select Profession
Practicing Physician
Physician Associate
Pharmacist
Registered Nurse
Nurse Practitioner/ Advanced Practice Registered Nurse
Licensed Practical Nurse/ Licensed Vocational Nurse
Medical, Dental, Podiatry, and Optometry Students
Nursing Student
Allied Health
Social Worker
Dentist
Dietitian
Other

Select Primary SpecialtyAddiction MedicineAdolescent MedicineAdult Medical Surgical PN - Nursing StudentAdult Medical Surgical RN - Nursing StudentAdvanced Cardiovascular Life Support® (ACLS®)Advanced Diabetes ManagementAdvanced Emergency Medicine Ultrasonography® (AEMUS®)Advanced Trauma Life Support® (ATLS®)Aerospace MedicineAlabama State CME CE RequirementsAlaska State CME CE RequirementsAllergy and ImmunologyAnatomy and Physiology - Nursing StudentAnesthesiology - Adult CardiacAnesthesiology - AdvancedAnesthesiology - BasicAnesthesiology - In-TrainingAnesthesiology - PediatricArizona State CME CE RequirementsArkansas State CME CE RequirementsAudiology Praxis®Australian Medical Council - IMG (AMC CAT MCQ)Brain Injury Medicine (BIM®)Calculations - Nursing StudentCalifornia State CME CE RequirementsCardiac SurgeryCardiology - Adult Congenital Heart DiseaseCardiology - Adult EchocardiographyCardiology - Advanced Heart Failure and Transplant CardiologyCardiology - Cardiovascular Computed TomographyCardiology - Cardiovascular DiseaseCardiology - Cardiovascular Magnetic ResonanceCardiology - Clinical Cardiac ElectrophysiologyCardiology - InterventionalCardiology - NuclearCardiothoracic - Congenital SurgeryCardiothoracic SurgeryCaribbean Association of Medical Councils (CAMC)Certified Anesthesiology Assistants (CAA®)Certified Dental Assistant™ (CDA®)Certified EKG Technician (CET)Certified Healthcare Simulation Educator (CHSE®)Certified Hyperbaric Technologist (CHT)Certified Hypertension Clinician (CHC®)Certified Hypertension Specialist (CHS®)Certified in Healthcare Compliance (CHC®)Certified Medical Assistant (AAMA® CMA®)Certified Nursing Assistant (CNA®)Certified Occupational Therapy Assistant® (COTA®)Certified Registered Nurse Anesthetist (CRNA NCE® or SEE®)Certified Surgical First Assistant™ (CSFA®)Certified Surgical Technologist™ (CST®)Child Health PN - Nursing StudentChild Health RN - Nursing StudentClinical InformaticsClinical Lipid Specialists (CLS®)Clinical Nutritionist (CCN/CNS)Clinical Tropical Medicine and Travelers' Health (CTropMed®)CNS - Acute Care Clinical Nurse Specialist - Neonatal (ACCNS-N®)CNS - Acute Care Clinical Nurse Specialist - Pediatric (ACCNS-P®)CNS - Adult-Gerontology Clinical Nurse Specialist (ACCNS-AG® or AGCNS-BC™)CNS - Advanced Diabetes Management (BC-ADM®)Colon and Rectal Surgery / ColorectalColorado State CME CE RequirementsCOMLEX-USA® Level 1COMLEX-USA® Level 2COMLEX-USA® Level 3Community Health - Nursing StudentComplex General Surgical Oncology (CGSO®)COMVEX®Connecticut State CME CE RequirementsCorrectional MedicineCosmetic Surgery (ABCS®)Critical Care and Basic Rhythms - Nursing StudentCritical Care MedicineDelaware State CME CE RequirementsDental Licensure Objective Structured Clinical Examination (DLOSCE™)Dermatology - AppliedDermatology - BasicDermatology - CoreDermatology - Micrographic Dermatologic Surgery (Mohs)Dermatology - PediatricDermatopathologyDisaster MedicineDistrict of Columbia CME CE RequirementsEgyptian Medical Licensing Exam (EMLE)Elder Adult Care - Nursing StudentEmergency MedicineEmergency Medicine - Emergency Medical Services (ABEM® EMS®)Emergency Medicine - FRCEM SBAEmergency Medicine - MRCEM PrimaryEmergency Medicine - MRCEM SBA-FRCEM IntermediateEmirates Medical Residency Entrance Examination (EMREE)EMS - Advanced Emergency Medical Technician (NREMT® AEMT®)EMS - Certified Flight Paramedic (IBSC FP-C®)EMS - Community Paramedic (IBSC CP-C®)EMS - Critical Care Paramedic (IBSC CCP-C®)EMS - Emergency Medical Responder (NREMT® EMR®)EMS - Emergency Medical Technician (NREMT® EMT®)EMS - Paramedic (NREMT®)EMS - Tactical Paramedic Certification (IBSC TP-C®)EMS - Wilderness Paramedic (IBSC WP-C®)ENARM MexicoEndocrinologyEndovascular MedicineFacial Cosmetic SurgeryFacial Plastic and Reconstructive SurgeryFamily MedicineFamily Medicine - MRCGP-Applied Knowledge TestFlorida State CME CE RequirementsFundamentals - Nursing StudentGastroenterologyGeneral SurgeryGeneral Surgery - In-Training ABSITE®General Surgery Review (All Subspecialties) - MRCS Part AGenetics and Genomics - ClinicalGenetics and Genomics - GeneralGeorgia State CME CE RequirementsGeriatricsGuam State CME CE RequirementsHand SurgeryHawaii State CME CE RequirementsHealth Assessment - Nursing StudentHealthcare Administration, Leadership, and Management (HALM®)Healthcare Ethics Consultant Exam (HEC-C)HematologyHospice And Palliative MedicineIdaho State CME CE RequirementsIllinois State CME CE RequirementsIndian PG Entrance (NEET-PG)Indiana State CME CE RequirementsInfectious DiseaseIntegrated National Board Dental Examination (INBDE®)Internal MedicineInternal Medicine - Focused Practice In Hospital MedicineInternal Medicine - MRCP UK and Ireland Part 1Internal Medicine - MRCP UK and Ireland Part 2International Trauma Life Support® (ITLS®)Iowa State CME CE RequirementsKansas State CME CE RequirementsKentucky State CME CE RequirementsLab - Medical Laboratory Scientist MLS(ASCP®)Lab - Medical Laboratory Technician MLT(ASCP®)Lab - Phlebotomy Technician PBT(ASCP®) or (NPS CPT®)Lab - Technologist in Blood Banking BB(ASCP®)Lab - Technologist in Chemistry C(ASCP®)Lab - Technologist in Hematology H(ASCP®)Lab - Technologist in Microbiology M(ASCP®)Lab and Diagnostic Testing - Nursing StudentLifestyle MedicineLouisiana State CME CE RequirementsMaine State CME CE RequirementsMaryland State CME CE RequirementsMassachusetts State CME CE RequirementsMaternal Newborn PN - Nursing StudentMaternal Newborn RN - Nursing StudentMCCQE Part I (Medical Council of Canada Qualifying Examination)Medical Council Nigeria (MDCN)Medical Student Elective - AllergyMedical Student Elective - AnesthesiologyMedical Student Elective - Biostatistics and EconomicsMedical Student Elective - Cardiothoracic SurgeryMedical Student Elective - Cardiovascular DiseaseMedical Student Elective - Critical CareMedical Student Elective - DermatologyMedical Student Elective - Diagnostic RadiologyMedical Student Elective - ECG and Rhythm Strip ReviewMedical Student Elective - EndocrinologyMedical Student Elective - GastroenterologyMedical Student Elective - GeneticsMedical Student Elective - GeriatricsMedical Student Elective - HandMedical Student Elective - HematologyMedical Student Elective - Infectious DiseaseMedical Student Elective - Law, Medicine, and EthicsMedical Student Elective - NeonatologyMedical Student Elective - NephrologyMedical Student Elective - NeurosurgeryMedical Student Elective - OncologyMedical Student Elective - OphthalmologyMedical Student Elective - OrthopedicMedical Student Elective - OtolaryngologyMedical Student Elective - Pathology, Clinical LaboratoryMedical Student Elective - Pediatric CardiologyMedical Student Elective - Pediatric Critical CareMedical Student Elective - Pediatric EndocrinologyMedical Student Elective - Pediatric GastroenterologyMedical Student Elective - Pediatric Hematology & OncologyMedical Student Elective - Pediatric Infectious DiseasesMedical Student Elective - Pediatric NephrologyMedical Student Elective - Pediatric NeurologyMedical Student Elective - Pediatric PulmonologyMedical Student Elective - Pediatric SurgeryMedical Student Elective - Physical Medicine and RehabilitationMedical Student Elective - Plastic SurgeryMedical Student Elective - PulmonologyMedical Student Elective - RheumatologyMedical Student Elective - Sports MedicineMedical Student Elective - UrologyMedical Student Elective - Vascular SurgeryMental Health PN - Nursing StudentMental Health RN - Nursing StudentMetabolic and Bariatric Surgery (MBS FPD®)Michigan State CME CE RequirementsMicrobiology - Nursing StudentMinnesota State CME CE RequirementsMississippi State CME CE RequirementsMissouri State CME CE RequirementsMontana State CME CE RequirementsMultistate Pharmacy Jurisprudence Examination® (MPJE®)National Board Dental Hygienist Examination (NBDHE®)NBME® Shelf - Ambulatory CareNBME® Shelf - AnatomyNBME® Shelf - Behavioral ScienceNBME® Shelf - BiochemistryNBME® Shelf - Clinical NeurologyNBME® Shelf - Comprehensive Basic Science (CBSE®)NBME® Shelf - Comprehensive Clinical Science (CCC®)NBME® Shelf - EmbryologyNBME® Shelf - Emergency MedicineNBME® Shelf - Family MedicineNBME® Shelf - Health Systems ScienceNBME® Shelf - HistologyNBME® Shelf - Internal Medicine (Advanced Clinical Exam)NBME® Shelf - Introduction to Clinical DiagnosisNBME® Shelf - MedicineNBME® Shelf - Microbiology and ImmunologyNBME® Shelf - NeuroscienceNBME® Shelf - Obstetrics and GynecologyNBME® Shelf - PathologyNBME® Shelf - PediatricsNBME® Shelf - PharmacologyNBME® Shelf - PhysiologyNBME® Shelf - PsychiatryNBME® Shelf - SurgeryNBOME® Subject Exam / Shelf - Osteopathic Principles and PracticeNCLEX-PN® - Nursing StudentNCLEX-RN® - Nursing StudentNebraska State CME CE RequirementsNepal Medical Council Licensing Examination (NMCLE)NephrologyNeurologyNeurology - Behavioral Neurology and NeuropsychiatryNeurology - Clinical NeurophysiologyNeurology - Epilepsy MedicineNeurology - HeadacheNeurology - Neurocritical CareNeurology - Neurodevelopmental DisabilitiesNeurology - Neuromuscular MedicineNeurology - Vascular NeurologyNeurosurgeryNevada State CME CE RequirementsNew Hampshire State CME CE RequirementsNew Jersey State CME CE RequirementsNew Mexico State CME CE RequirementsNew York State CME CE RequirementsNorth Carolina State CME CE RequirementsNorth Dakota State CME CE RequirementsNP - Adult-Gerontology Acute Care Nurse Practitioner (AGACNP® or ACNPC-AG®)NP - Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP® or AGNP®)NP - Advanced Certified Hospice and Palliative Nurse (ACHPN®)NP - Advanced Health Assessment and Diagnostic Reasoning Nurse PractitionerNP - Advanced Neurovascular Practitioner Certification (ANVP-BC®)NP - Advanced Oncology Certified Nurse Practitioner (AOCNP®)NP - Advanced Pathophysiology Nurse PractitionerNP - Advanced Pharmacology Nurse PractitionerNP - Advanced Physiology Nurse PractitionerNP - Biostatistics and Epidemiology Nurse PractitionerNP - Board Certified Advanced Diabetes Management (BC-ADM®)NP - Cardiovascular Nurse Practitioner (CVNP-BC®)NP - Certified Addictions Registered Nurse - Advanced Practice (CARN-AP®)NP - Certified Continence Care Nurse - Advanced Practice (CCCN-AP®)NP - Certified Midwife (CNM®/CM®)NP - Certified Nephrology Nurse - Nurse Practitioner™ (CNN-NP™)NP - Certified Ostomy Care Nurse - Advanced Practice (COCN-AP®)NP - Certified Pediatric Nurse Practitioner - Acute Care (CPNP-AC®)NP - Certified Pediatric Nurse Practitioner – Primary Care (CPNP-PC®)NP - Certified Urologic Nurse Practitioner (CUNP®)NP - Certified Wound Care Nurse - Advanced Practice (CWCN-AP® / AWCC™)NP - Certified Wound Ostomy Continence Nurse - Adv. Practice (CWOCN-AP®)NP - Dermatology Certified Nurse Practitioner (DCNP®)NP - Emergency Nurse Practitioner (ENP®)NP - Ethics & Legal Issues Nurse PractitionerNP - Family Nurse Practitioner (ANCC/FNP-BC™ or AANP/FNP-C®)NP - Health Promotion and Disease Prevention Nurse PractitionerNP - Neonatal Nurse Practitioner (NNP-BC®)NP - Nurse Executive Advanced Certification (NEA-BC®)NP - Orthopedic Nurse Practitioner (ONP-C®)NP - Pediatric Primary Care Mental Health Specialist (PMHS®)NP - Psychiatric-Mental Health Nurse Practitioner Certification (PMHNP-BC™)NP - Theory and Evidence-Based Practice Nurse PractitionerNP - Women's Health Nurse Practitioner (WHNP®)Nuclear MedicineNurse - Ambulatory Care Nursing Certification (AMB-BC™)Nurse - Assisted Living Nursing Certification (C-AL®)Nurse - Bariatric (CBN®)Nurse - Cardiac Medicine Certification (CMC®) AdultNurse - Cardiac-Vascular Nursing Certification (CV-BC™)Nurse - Cardiovascular Nursing (CVN®)Nurse - Case Management Certification (CMGT-BC™)Nurse - Certified Addictions Registered Nurse (CARN®)Nurse - Certified Anticoagulation Care Provider (CACP®)Nurse - Certified Breast Care Nurse (CBCN®)Nurse - Certified Clinical Transplant Nurse (CCTN®)Nurse - Certified Continence Care Nurse (CCCN®)Nurse - Certified Diabetes Care and Education Specialist® (CDCES®)Nurse - Certified Emergency Nurse® (CEN®)Nurse - Certified Flight Registered Nurse (CFRN®)Nurse - Certified Foot Care Nurse (CFCN®)Nurse - Certified Gastroenterology Registered Nurse (CGRN®)Nurse - Certified Hemodialysis Nurse (CHN®)Nurse - Certified Hospice and Palliative Nurse (CHPN®)Nurse - Certified Hyperbaric Registered Nurse® (CHRN®)Nurse - Certified Infection Control (CIC®)Nurse - Certified Managed Care Nurse (CMCN®)Nurse - Certified Nephrology Nurse (CNN®)Nurse - Certified Neuroscience Registered Nurse (CNRN®)Nurse - Certified Nurse Educator (CNE®)Nurse - Certified Nurse Manager and Leader (CNML®)Nurse - Certified Occupational Health Nurse (COHN® and COHN-S®)Nurse - Certified Ostomy Care (COCN®) / Ostomy Management Specialist (OMS®)Nurse - Certified Otorhinolaryngology Nurse (CORLN®)Nurse - Certified Pediatric Emergency Nurse (CPEN®)Nurse - Certified Pediatric Hematology Oncology Nurse (CPHON®)Nurse - Certified Pediatric Nurse (CPN®)Nurse - Certified Perioperative Nurse (CNOR®)Nurse - Certified Peritoneal Dialysis Nurse (CPDN®)Nurse - Certified Plastic Surgery Nurse (CPSN®)Nurse - Certified Post and Ambulatory Perianesthesia Nurse (CPAN® / CAPA®)Nurse - Certified Professional in Health Care Risk Management (CPHRM®)Nurse - Certified Professional in Healthcare Quality (CPHQ®)Nurse - Certified Radiology Nurse (CRN©)Nurse - Certified Registered Nurse in Ophthalmology (CRNO®)Nurse - Certified Registered Nurse Infusion (CRNI®)Nurse - Certified Rehabilitation Registered Nurse (CRRN®)Nurse - Certified Transport Registered Nurse (CTRN®)Nurse - Certified Urologic Registered Nurse (CURN®)Nurse - Certified Wound Care Nurse (CWCN® / WCC®)Nurse - Critical Care Registered Nurse - Adult (CCRN®)Nurse - Critical Care Registered Nurse - Neonatal (CCRN®)Nurse - Critical Care Registered Nurse - Pediatric (CCRN®)Nurse - Dermatology Nurse Certified (DNC®)Nurse - Emergency Nurse Pediatric Certification© (ENPC®)Nurse - Gerontology Nursing Certification (GERO-BC™)Nurse - Informatics Nursing Certification (NI-BC™)Nurse - Inpatient Obstetric Nursing (RNC-OB®)Nurse - International Board Certified Lactation Consultant® (IBCLC®)Nurse - Low Risk Neonatal Intensive Care Nursing (RNC-LRN®)Nurse - Maternal Newborn Nursing (MNN®)Nurse - Medical-Surgical Nursing Certification (MEDSURG-BC™)Nurse - Nationally Certified School Nurse (NCSN®)Nurse - Neonatal Pediatric Transport (C-NPT®)Nurse - Nurse Executive Certification (NE-BC®)Nurse - Nursing Professional Development Certification (NPD-BC™)Nurse - Oncology Certified Nurse (OCN®)Nurse - Orthopedic Nurse Certification (ONC®)Nurse - Pain Management Nursing Certification (PMGT-BC™)Nurse - Progressive Care Certified Nurse (PCCN®) - AdultNurse - Psychiatric-Mental Health Nursing Certification (PMH-BC™)Nurse - Registered Nurse First Assistant (RNFA©)Nurse - Sexual Assault Nurse Examiner (SANE®)Nurse - Stroke Certified Registered Nurse (SC-RN®)Nurse - Trauma Certified Registered Nurse (TCRN®)Nurse - Vascular Access Board Certified Nursing (VA-BC®)Nutrition - Nursing StudentNutrition MedicineObesity MedicineOb-Gyn - CREOG® In-ServiceOb-Gyn - Gynecologic OncologyOb-Gyn - Maternal-Fetal MedicineOb-Gyn - MRCOG UK and Ireland Part 1Ob-Gyn - MRCOG UK and Ireland Part 2 and Part 3Ob-Gyn - Obstetrics and GynecologyOb-Gyn - Reproductive Endocrinology and InfertilityOb-Gyn - Urogynecology and Reconstructive Pelvic SurgeryOccupational MedicineOccupational Therapist Registered (NBCOT® OTR®)Ohio State CME CE RequirementsOklahoma State CME CE RequirementsOncologyOphthalmologyOphthalmology - CataractOphthalmology - Cornea and External Eye DiseaseOphthalmology - GlaucomaOphthalmology - Medical and Surgical RetinaOphthalmology - Neuro-OphthalmologyOphthalmology - Oculoplastic SurgeryOphthalmology - OpticsOphthalmology - Pediatric and StrabismusOphthalmology - UveitisOphthamology - TraumaOptometry - Advanced Medical CareOptometry - Applied Basic Science (ABS®)Optometry - Patient Assessment and Management (PAM®)Oral And Maxillofacial SurgeryOregon State CME CE RequirementsOrthopedic SurgeryOsteopathic Neuromusculoskeletal Medicine (OMT/NMM®/OMM®)Otolaryngology - Head and Neck SurgeryPA - Cardiovascular and Thoracic Surgery (CAQ-CVTS®)PA - Cardiovascular Physician Assistant/Associate (CVPA-BC®)PA - Clinical Knowledge Rating and AssessmentPA - Dermatology (CAQ-Derm® or NBDPA™)PA - Emergency Medicine (CAQ-EM®)PA - Emergency Medicine End of RotationPA - End of CurriculumPA - Family Medicine End of RotationPA - Hospital Medicine (CAQ-HM®)PA - Internal Medicine End of RotationPA - Nephrology (CAQ-Neph®)PA - Obstetrics and Gynecology (CAQ-OBGYN®)PA - Occupational Medicine (CAQ-OM®)PA - Orthopedic (CAQ-OS®)PA - Palliative Medicine and Hospice Care (CAQ-PMHC®)PA - PANCE®PA - PANRE®PA - Pediatric (CAQ-Peds®)PA - Pediatric End of RotationPA - Psychiatric and Behavioral Health End of RotationPA - Psychiatry (CAQ-Psy®)PA - Surgery End of RotationPA - Womens Health End of Rotation (Gyn, Sexual, & Reproductive Health)Pain MedicinePakistan - 1st Professional MBBSPakistan - 2nd Professional MBBSPakistan - 3rd Professional MBBSPakistan - 4th Professional MBBSPakistan - Final Professional MBBSPakistan FCPS Part I (Basic Science)Pathology - AnatomicPathology - Blood Banking Transfusion MedicinePathology - ChemicalPathology - ClinicalPathology - CytopathologyPathology - ForensicsPathology - HematopathologyPathology - MicrobiologyPathology - Molecular GeneticPathology - NeuropathologyPathology - PediatricPathophysiology - Nursing StudentPediatricPediatric - CardiologyPediatric - Child AbusePediatric - Critical CarePediatric - Developmental BehavioralPediatric - Emergency MedicinePediatric - EndocrinologyPediatric - GastroenterologyPediatric - Hematology-OncologyPediatric - Hospital MedicinePediatric - Infectious DiseasesPediatric - MRCPCH UKPediatric - Neonatal PerinatalPediatric - NephrologyPediatric - NeurologyPediatric - PulmonologyPediatric - Rehabilitation MedicinePediatric - RheumatologyPediatric Advanced Life Support® (PALS®)Pediatric SurgeryPennsylvania State CME CE RequirementsPharmacology PN - Nursing StudentPharmacology RN - Nursing StudentPharmacy - Ambulatory Care (BCACP®)Pharmacy - Applied Toxicology (ABAT®)Pharmacy - Cardiology (BCCP®)Pharmacy - Certified Pharmacy Technician (PTCB® CPhT®)Pharmacy - Critical Care (BCCCP®)Pharmacy - Emergency Medicine (BCEMP®)Pharmacy - Geriatric (BCGP®)Pharmacy - Infectious Disease (BCIDP®)Pharmacy - NAPLEX®Pharmacy - Nutrition Support (BCNSP®)Pharmacy - Oncology (BCOP®)Pharmacy - Pediatric (BCPPS®)Pharmacy - Pharmacotherapy (BCPS®)Pharmacy - Psychiatric (BCPP®)Physical Medicine and RehabilitationPhysical Therapy - Geriatric Clinical Specialist (ABPTS® APTA® GCS)Physical Therapy - Neurology Clinical Specialist (ABPTS® APTA® NCS)Physical Therapy - Orthopedic Clinical Specialist (ABPTS® APTA® OCS)Physical Therapy - Pediatric Clinical Specialist (ABPTS® APTA® PCS)Physical Therapy - Physical Therapist (NPTE-PT)®Physical Therapy - Physical Therapist Assistant (NPTE-PTA)®Physical Therapy - Sports Clinical Specialist (ABPTS® APTA® SCS)Plastic SurgeryPodiatry - APMLE® Part 1Podiatry - APMLE® Part 2Podiatry - APMLE® Part 3Podiatry Foot and Ankle SurgeryPodiatry MedicineProfessional Ethics, Leadership, and Management - Nursing StudentPsychiatryPsychiatry - AddictionPsychiatry - Child and AdolescentPsychiatry - Consultation-LiaisonPsychiatry - ForensicPsychiatry - GeriatricPsychology - Examination for Professional Practice In Psychology (EPPP®)Psychology - NeuropsychologyPsychology - Psychopharmacology Examination (PEP®)Public Health and General Preventive MedicinePuerto Rico State CME CE RequirementsPulmonaryQuality BoardRadiation OncologyRadiologic Technologist - Magnetic Resonance Imaging (ARRT-MRI®)Radiologic Technologist - Radiography (ARRT-R®)Radiology - BreastRadiology - CardiacRadiology - Diagnostic Radiology Qualifying (Core)Radiology - GastrointestinalRadiology - GenitourinaryRadiology - MusculoskeletalRadiology - NeuroradiologyRadiology - PediatricRadiology - Physics and SafetyRadiology - ThoracicRadiology - UltrasoundRadiology - Vascular and InterventionalRadiology Technology - Computed Tomography (ARRT-CT® or NMTCB-CT®)Radiology Technology - Nuclear Medicine (ARRT® or NMTCB-CNMT®)Radiology Technology - Vascular Interventional RadiographyRegistered Cardiovascular Invasive Specialist (RCIS)®Registered Dietitian (RD®) / Registered Dietitian Nutritionist (RDN®)Respiratory Therapist - Certified or Registered (CRT® or RRT®)Respiratory Therapy - Adult Critical Care Specialist (RRT-ACCS®)Respiratory Therapy - Neonatal and Pediatric (RRT-NPS®)Respiratory Therapy - Pulmonary Function Technologist (CPFT® or RPFT®)RheumatologyRhode Island State CME CE RequirementsSleepSocial Work - ASWB® Advanced GeneralistSocial Work - ASWB® Bachelors and AssociateSocial Work - ASWB® ClinicalSocial Work - ASWB® MastersSonography - Cardiac SonographerSonography - Registered Diagnostic Medical Sonographer® (RDMS-Ob/Gyn®)Sonography - Registered Diagnostic Medical Sonographer®-Abdomen (RDMS-AB®)Sonography - Vascular (ADRMS® RVT®, ARRT® VS®, CCI® RVS®)South Carolina State CME CE RequirementsSouth Dakota State CME CE RequirementsSpeech-Language Pathology Praxis® (SLP®)SPEX®Spinal Cord Injury MedicineSpine SurgerySports MedicineSurgical Critical CareTennessee State CME CE RequirementsTexas State CME CE RequirementsThoracic SurgeryToxicologyTransesophageal EchocardiographyTransplant HepatologyUK - Medical Licensing Assessment (UKMLA/MLA)UK - Multi-Specialty Recruitment Assessment (MSRA - CPS)UK - Prescribing Safety Assessment (PSA)UK Overseas Registration (ORE)UK PLAB 1Undersea and HyperbaricUrologyUrology - PediatricUSMLE® Step 1USMLE® Step 2USMLE® Step 3Utah State CME CE RequirementsVascular Medicine (ABVMVascular Medicine (ABVM®)Vascular SurgeryVenous, Lymphatic, and Phlebology MedicineVermont State CME CE RequirementsVirgin Islands State CME CE RequirementsVirginia State CME CE RequirementsWashington State CME CE RequirementsWest Virginia State CME CE RequirementsWisconsin State CME CE RequirementsWoundWyoming State CME CE Requirements

Select Primary Specialty

Select Primary Specialty
Addiction Medicine
Adolescent Medicine
Adult Medical Surgical PN - Nursing Student
Adult Medical Surgical RN - Nursing Student
Advanced Cardiovascular Life Support® (ACLS®)
Advanced Diabetes Management
Advanced Emergency Medicine Ultrasonography® (AEMUS®)
Advanced Trauma Life Support® (ATLS®)
Aerospace Medicine
Alabama State CME CE Requirements
Alaska State CME CE Requirements
Allergy and Immunology
Anatomy and Physiology - Nursing Student
Anesthesiology - Adult Cardiac
Anesthesiology - Advanced
Anesthesiology - Basic
Anesthesiology - In-Training
Anesthesiology - Pediatric
Arizona State CME CE Requirements
Arkansas State CME CE Requirements
Audiology Praxis®
Australian Medical Council - IMG (AMC CAT MCQ)
Brain Injury Medicine (BIM®)
Calculations - Nursing Student
California State CME CE Requirements
Cardiac Surgery
Cardiology - Adult Congenital Heart Disease
Cardiology - Adult Echocardiography
Cardiology - Advanced Heart Failure and Transplant Cardiology
Cardiology - Cardiovascular Computed Tomography
Cardiology - Cardiovascular Disease
Cardiology - Cardiovascular Magnetic Resonance
Cardiology - Clinical Cardiac Electrophysiology
Cardiology - Interventional
Cardiology - Nuclear
Cardiothoracic - Congenital Surgery
Cardiothoracic Surgery
Caribbean Association of Medical Councils (CAMC)
Certified Anesthesiology Assistants (CAA®)
Certified Dental Assistant™ (CDA®)
Certified EKG Technician (CET)
Certified Healthcare Simulation Educator (CHSE®)
Certified Hyperbaric Technologist (CHT)
Certified Hypertension Clinician (CHC®)
Certified Hypertension Specialist (CHS®)
Certified in Healthcare Compliance (CHC®)
Certified Medical Assistant (AAMA® CMA®)
Certified Nursing Assistant (CNA®)
Certified Occupational Therapy Assistant® (COTA®)
Certified Registered Nurse Anesthetist (CRNA NCE® or SEE®)
Certified Surgical First Assistant™ (CSFA®)
Certified Surgical Technologist™ (CST®)
Child Health PN - Nursing Student
Child Health RN - Nursing Student
Clinical Informatics
Clinical Lipid Specialists (CLS®)
Clinical Nutritionist (CCN/CNS)
Clinical Tropical Medicine and Travelers' Health (CTropMed®)
CNS - Acute Care Clinical Nurse Specialist - Neonatal (ACCNS-N®)
CNS - Acute Care Clinical Nurse Specialist - Pediatric (ACCNS-P®)
CNS - Adult-Gerontology Clinical Nurse Specialist (ACCNS-AG® or AGCNS-BC™)
CNS - Advanced Diabetes Management (BC-ADM®)
Colon and Rectal Surgery / Colorectal
Colorado State CME CE Requirements
COMLEX-USA® Level 1
COMLEX-USA® Level 2
COMLEX-USA® Level 3
Community Health - Nursing Student
Complex General Surgical Oncology (CGSO®)
COMVEX®
Connecticut State CME CE Requirements
Correctional Medicine
Cosmetic Surgery (ABCS®)
Critical Care and Basic Rhythms - Nursing Student
Critical Care Medicine
Delaware State CME CE Requirements
Dental Licensure Objective Structured Clinical Examination (DLOSCE™)
Dermatology - Applied
Dermatology - Basic
Dermatology - Core
Dermatology - Micrographic Dermatologic Surgery (Mohs)
Dermatology - Pediatric
Dermatopathology
Disaster Medicine
District of Columbia CME CE Requirements
Egyptian Medical Licensing Exam (EMLE)
Elder Adult Care - Nursing Student
Emergency Medicine
Emergency Medicine - Emergency Medical Services (ABEM® EMS®)
Emergency Medicine - FRCEM SBA
Emergency Medicine - MRCEM Primary
Emergency Medicine - MRCEM SBA-FRCEM Intermediate
Emirates Medical Residency Entrance Examination (EMREE)
EMS - Advanced Emergency Medical Technician (NREMT® AEMT®)
EMS - Certified Flight Paramedic (IBSC FP-C®)
EMS - Community Paramedic (IBSC CP-C®)
EMS - Critical Care Paramedic (IBSC CCP-C®)
EMS - Emergency Medical Responder (NREMT® EMR®)
EMS - Emergency Medical Technician (NREMT® EMT®)
EMS - Paramedic (NREMT®)
EMS - Tactical Paramedic Certification (IBSC TP-C®)
EMS - Wilderness Paramedic (IBSC WP-C®)
ENARM Mexico
Endocrinology
Endovascular Medicine
Facial Cosmetic Surgery
Facial Plastic and Reconstructive Surgery
Family Medicine
Family Medicine - MRCGP-Applied Knowledge Test
Florida State CME CE Requirements
Fundamentals - Nursing Student
Gastroenterology
General Surgery
General Surgery - In-Training ABSITE®
General Surgery Review (All Subspecialties) - MRCS Part A
Genetics and Genomics - Clinical
Genetics and Genomics - General
Georgia State CME CE Requirements
Geriatrics
Guam State CME CE Requirements
Hand Surgery
Hawaii State CME CE Requirements
Health Assessment - Nursing Student
Healthcare Administration, Leadership, and Management (HALM®)
Healthcare Ethics Consultant Exam (HEC-C)
Hematology
Hospice And Palliative Medicine
Idaho State CME CE Requirements
Illinois State CME CE Requirements
Indian PG Entrance (NEET-PG)
Indiana State CME CE Requirements
Infectious Disease
Integrated National Board Dental Examination (INBDE®)
Internal Medicine
Internal Medicine - Focused Practice In Hospital Medicine
Internal Medicine - MRCP UK and Ireland Part 1
Internal Medicine - MRCP UK and Ireland Part 2
International Trauma Life Support® (ITLS®)
Iowa State CME CE Requirements
Kansas State CME CE Requirements
Kentucky State CME CE Requirements
Lab - Medical Laboratory Scientist MLS(ASCP®)
Lab - Medical Laboratory Technician MLT(ASCP®)
Lab - Phlebotomy Technician PBT(ASCP®) or (NPS CPT®)
Lab - Technologist in Blood Banking BB(ASCP®)
Lab - Technologist in Chemistry C(ASCP®)
Lab - Technologist in Hematology H(ASCP®)
Lab - Technologist in Microbiology M(ASCP®)
Lab and Diagnostic Testing - Nursing Student
Lifestyle Medicine
Louisiana State CME CE Requirements
Maine State CME CE Requirements
Maryland State CME CE Requirements
Massachusetts State CME CE Requirements
Maternal Newborn PN - Nursing Student
Maternal Newborn RN - Nursing Student
MCCQE Part I (Medical Council of Canada Qualifying Examination)
Medical Council Nigeria (MDCN)
Medical Student Elective - Allergy
Medical Student Elective - Anesthesiology
Medical Student Elective - Biostatistics and Economics
Medical Student Elective - Cardiothoracic Surgery
Medical Student Elective - Cardiovascular Disease
Medical Student Elective - Critical Care
Medical Student Elective - Dermatology
Medical Student Elective - Diagnostic Radiology
Medical Student Elective - ECG and Rhythm Strip Review
Medical Student Elective - Endocrinology
Medical Student Elective - Gastroenterology
Medical Student Elective - Genetics
Medical Student Elective - Geriatrics
Medical Student Elective - Hand
Medical Student Elective - Hematology
Medical Student Elective - Infectious Disease
Medical Student Elective - Law, Medicine, and Ethics
Medical Student Elective - Neonatology
Medical Student Elective - Nephrology
Medical Student Elective - Neurosurgery
Medical Student Elective - Oncology
Medical Student Elective - Ophthalmology
Medical Student Elective - Orthopedic
Medical Student Elective - Otolaryngology
Medical Student Elective - Pathology, Clinical Laboratory
Medical Student Elective - Pediatric Cardiology
Medical Student Elective - Pediatric Critical Care
Medical Student Elective - Pediatric Endocrinology
Medical Student Elective - Pediatric Gastroenterology
Medical Student Elective - Pediatric Hematology & Oncology
Medical Student Elective - Pediatric Infectious Diseases
Medical Student Elective - Pediatric Nephrology
Medical Student Elective - Pediatric Neurology
Medical Student Elective - Pediatric Pulmonology
Medical Student Elective - Pediatric Surgery
Medical Student Elective - Physical Medicine and Rehabilitation
Medical Student Elective - Plastic Surgery
Medical Student Elective - Pulmonology
Medical Student Elective - Rheumatology
Medical Student Elective - Sports Medicine
Medical Student Elective - Urology
Medical Student Elective - Vascular Surgery
Mental Health PN - Nursing Student
Mental Health RN - Nursing Student
Metabolic and Bariatric Surgery (MBS FPD®)
Michigan State CME CE Requirements
Microbiology - Nursing Student
Minnesota State CME CE Requirements
Mississippi State CME CE Requirements
Missouri State CME CE Requirements
Montana State CME CE Requirements
Multistate Pharmacy Jurisprudence Examination® (MPJE®)
National Board Dental Hygienist Examination (NBDHE®)
NBME® Shelf - Ambulatory Care
NBME® Shelf - Anatomy
NBME® Shelf - Behavioral Science
NBME® Shelf - Biochemistry
NBME® Shelf - Clinical Neurology
NBME® Shelf - Comprehensive Basic Science (CBSE®)
NBME® Shelf - Comprehensive Clinical Science (CCC®)
NBME® Shelf - Embryology
NBME® Shelf - Emergency Medicine
NBME® Shelf - Family Medicine
NBME® Shelf - Health Systems Science
NBME® Shelf - Histology
NBME® Shelf - Internal Medicine (Advanced Clinical Exam)
NBME® Shelf - Introduction to Clinical Diagnosis
NBME® Shelf - Medicine
NBME® Shelf - Microbiology and Immunology
NBME® Shelf - Neuroscience
NBME® Shelf - Obstetrics and Gynecology
NBME® Shelf - Pathology
NBME® Shelf - Pediatrics
NBME® Shelf - Pharmacology
NBME® Shelf - Physiology
NBME® Shelf - Psychiatry
NBME® Shelf - Surgery
NBOME® Subject Exam / Shelf - Osteopathic Principles and Practice
NCLEX-PN® - Nursing Student
NCLEX-RN® - Nursing Student
Nebraska State CME CE Requirements
Nepal Medical Council Licensing Examination (NMCLE)
Nephrology
Neurology
Neurology - Behavioral Neurology and Neuropsychiatry
Neurology - Clinical Neurophysiology
Neurology - Epilepsy Medicine
Neurology - Headache
Neurology - Neurocritical Care
Neurology - Neurodevelopmental Disabilities
Neurology - Neuromuscular Medicine
Neurology - Vascular Neurology
Neurosurgery
Nevada State CME CE Requirements
New Hampshire State CME CE Requirements
New Jersey State CME CE Requirements
New Mexico State CME CE Requirements
New York State CME CE Requirements
North Carolina State CME CE Requirements
North Dakota State CME CE Requirements
NP - Adult-Gerontology Acute Care Nurse Practitioner (AGACNP® or ACNPC-AG®)
NP - Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP® or AGNP®)
NP - Advanced Certified Hospice and Palliative Nurse (ACHPN®)
NP - Advanced Health Assessment and Diagnostic Reasoning Nurse Practitioner
NP - Advanced Neurovascular Practitioner Certification (ANVP-BC®)
NP - Advanced Oncology Certified Nurse Practitioner (AOCNP®)
NP - Advanced Pathophysiology Nurse Practitioner
NP - Advanced Pharmacology Nurse Practitioner
NP - Advanced Physiology Nurse Practitioner
NP - Biostatistics and Epidemiology Nurse Practitioner
NP - Board Certified Advanced Diabetes Management (BC-ADM®)
NP - Cardiovascular Nurse Practitioner (CVNP-BC®)
NP - Certified Addictions Registered Nurse - Advanced Practice (CARN-AP®)
NP - Certified Continence Care Nurse - Advanced Practice (CCCN-AP®)
NP - Certified Midwife (CNM®/CM®)
NP - Certified Nephrology Nurse - Nurse Practitioner™ (CNN-NP™)
NP - Certified Ostomy Care Nurse - Advanced Practice (COCN-AP®)
NP - Certified Pediatric Nurse Practitioner - Acute Care (CPNP-AC®)
NP - Certified Pediatric Nurse Practitioner – Primary Care (CPNP-PC®)
NP - Certified Urologic Nurse Practitioner (CUNP®)
NP - Certified Wound Care Nurse - Advanced Practice (CWCN-AP® / AWCC™)
NP - Certified Wound Ostomy Continence Nurse - Adv. Practice (CWOCN-AP®)
NP - Dermatology Certified Nurse Practitioner (DCNP®)
NP - Emergency Nurse Practitioner (ENP®)
NP - Ethics & Legal Issues Nurse Practitioner
NP - Family Nurse Practitioner (ANCC/FNP-BC™ or AANP/FNP-C®)
NP - Health Promotion and Disease Prevention Nurse Practitioner
NP - Neonatal Nurse Practitioner (NNP-BC®)
NP - Nurse Executive Advanced Certification (NEA-BC®)
NP - Orthopedic Nurse Practitioner (ONP-C®)
NP - Pediatric Primary Care Mental Health Specialist (PMHS®)
NP - Psychiatric-Mental Health Nurse Practitioner Certification (PMHNP-BC™)
NP - Theory and Evidence-Based Practice Nurse Practitioner
NP - Women's Health Nurse Practitioner (WHNP®)
Nuclear Medicine
Nurse - Ambulatory Care Nursing Certification (AMB-BC™)
Nurse - Assisted Living Nursing Certification (C-AL®)
Nurse - Bariatric (CBN®)
Nurse - Cardiac Medicine Certification (CMC®) Adult
Nurse - Cardiac-Vascular Nursing Certification (CV-BC™)
Nurse - Cardiovascular Nursing (CVN®)
Nurse - Case Management Certification (CMGT-BC™)
Nurse - Certified Addictions Registered Nurse (CARN®)
Nurse - Certified Anticoagulation Care Provider (CACP®)
Nurse - Certified Breast Care Nurse (CBCN®)
Nurse - Certified Clinical Transplant Nurse (CCTN®)
Nurse - Certified Continence Care Nurse (CCCN®)
Nurse - Certified Diabetes Care and Education Specialist® (CDCES®)
Nurse - Certified Emergency Nurse® (CEN®)
Nurse - Certified Flight Registered Nurse (CFRN®)
Nurse - Certified Foot Care Nurse (CFCN®)
Nurse - Certified Gastroenterology Registered Nurse (CGRN®)
Nurse - Certified Hemodialysis Nurse (CHN®)
Nurse - Certified Hospice and Palliative Nurse (CHPN®)
Nurse - Certified Hyperbaric Registered Nurse® (CHRN®)
Nurse - Certified Infection Control (CIC®)
Nurse - Certified Managed Care Nurse (CMCN®)
Nurse - Certified Nephrology Nurse (CNN®)
Nurse - Certified Neuroscience Registered Nurse (CNRN®)
Nurse - Certified Nurse Educator (CNE®)
Nurse - Certified Nurse Manager and Leader (CNML®)
Nurse - Certified Occupational Health Nurse (COHN® and COHN-S®)
Nurse - Certified Ostomy Care (COCN®) / Ostomy Management Specialist (OMS®)
Nurse - Certified Otorhinolaryngology Nurse (CORLN®)
Nurse - Certified Pediatric Emergency Nurse (CPEN®)
Nurse - Certified Pediatric Hematology Oncology Nurse (CPHON®)
Nurse - Certified Pediatric Nurse (CPN®)
Nurse - Certified Perioperative Nurse (CNOR®)
Nurse - Certified Peritoneal Dialysis Nurse (CPDN®)
Nurse - Certified Plastic Surgery Nurse (CPSN®)
Nurse - Certified Post and Ambulatory Perianesthesia Nurse (CPAN® / CAPA®)
Nurse - Certified Professional in Health Care Risk Management (CPHRM®)
Nurse - Certified Professional in Healthcare Quality (CPHQ®)
Nurse - Certified Radiology Nurse (CRN©)
Nurse - Certified Registered Nurse in Ophthalmology (CRNO®)
Nurse - Certified Registered Nurse Infusion (CRNI®)
Nurse - Certified Rehabilitation Registered Nurse (CRRN®)
Nurse - Certified Transport Registered Nurse (CTRN®)
Nurse - Certified Urologic Registered Nurse (CURN®)
Nurse - Certified Wound Care Nurse (CWCN® / WCC®)
Nurse - Critical Care Registered Nurse - Adult (CCRN®)
Nurse - Critical Care Registered Nurse - Neonatal (CCRN®)
Nurse - Critical Care Registered Nurse - Pediatric (CCRN®)
Nurse - Dermatology Nurse Certified (DNC®)
Nurse - Emergency Nurse Pediatric Certification© (ENPC®)
Nurse - Gerontology Nursing Certification (GERO-BC™)
Nurse - Informatics Nursing Certification (NI-BC™)
Nurse - Inpatient Obstetric Nursing (RNC-OB®)
Nurse - International Board Certified Lactation Consultant® (IBCLC®)
Nurse - Low Risk Neonatal Intensive Care Nursing (RNC-LRN®)
Nurse - Maternal Newborn Nursing (MNN®)
Nurse - Medical-Surgical Nursing Certification (MEDSURG-BC™)
Nurse - Nationally Certified School Nurse (NCSN®)
Nurse - Neonatal Pediatric Transport (C-NPT®)
Nurse - Nurse Executive Certification (NE-BC®)
Nurse - Nursing Professional Development Certification (NPD-BC™)
Nurse - Oncology Certified Nurse (OCN®)
Nurse - Orthopedic Nurse Certification (ONC®)
Nurse - Pain Management Nursing Certification (PMGT-BC™)
Nurse - Progressive Care Certified Nurse (PCCN®) - Adult
Nurse - Psychiatric-Mental Health Nursing Certification (PMH-BC™)
Nurse - Registered Nurse First Assistant (RNFA©)
Nurse - Sexual Assault Nurse Examiner (SANE®)
Nurse - Stroke Certified Registered Nurse (SC-RN®)
Nurse - Trauma Certified Registered Nurse (TCRN®)
Nurse - Vascular Access Board Certified Nursing (VA-BC®)
Nutrition - Nursing Student
Nutrition Medicine
Obesity Medicine
Ob-Gyn - CREOG® In-Service
Ob-Gyn - Gynecologic Oncology
Ob-Gyn - Maternal-Fetal Medicine
Ob-Gyn - MRCOG UK and Ireland Part 1
Ob-Gyn - MRCOG UK and Ireland Part 2 and Part 3
Ob-Gyn - Obstetrics and Gynecology
Ob-Gyn - Reproductive Endocrinology and Infertility
Ob-Gyn - Urogynecology and Reconstructive Pelvic Surgery
Occupational Medicine
Occupational Therapist Registered (NBCOT® OTR®)
Ohio State CME CE Requirements
Oklahoma State CME CE Requirements
Oncology
Ophthalmology
Ophthalmology - Cataract
Ophthalmology - Cornea and External Eye Disease
Ophthalmology - Glaucoma
Ophthalmology - Medical and Surgical Retina
Ophthalmology - Neuro-Ophthalmology
Ophthalmology - Oculoplastic Surgery
Ophthalmology - Optics
Ophthalmology - Pediatric and Strabismus
Ophthalmology - Uveitis
Ophthamology - Trauma
Optometry - Advanced Medical Care
Optometry - Applied Basic Science (ABS®)
Optometry - Patient Assessment and Management (PAM®)
Oral And Maxillofacial Surgery
Oregon State CME CE Requirements
Orthopedic Surgery
Osteopathic Neuromusculoskeletal Medicine (OMT/NMM®/OMM®)
Otolaryngology - Head and Neck Surgery
PA - Cardiovascular and Thoracic Surgery (CAQ-CVTS®)
PA - Cardiovascular Physician Assistant/Associate (CVPA-BC®)
PA - Clinical Knowledge Rating and Assessment
PA - Dermatology (CAQ-Derm® or NBDPA™)
PA - Emergency Medicine (CAQ-EM®)
PA - Emergency Medicine End of Rotation
PA - End of Curriculum
PA - Family Medicine End of Rotation
PA - Hospital Medicine (CAQ-HM®)
PA - Internal Medicine End of Rotation
PA - Nephrology (CAQ-Neph®)
PA - Obstetrics and Gynecology (CAQ-OBGYN®)
PA - Occupational Medicine (CAQ-OM®)
PA - Orthopedic (CAQ-OS®)
PA - Palliative Medicine and Hospice Care (CAQ-PMHC®)
PA - PANCE®
PA - PANRE®
PA - Pediatric (CAQ-Peds®)
PA - Pediatric End of Rotation
PA - Psychiatric and Behavioral Health End of Rotation
PA - Psychiatry (CAQ-Psy®)
PA - Surgery End of Rotation
PA - Womens Health End of Rotation (Gyn, Sexual, & Reproductive Health)
Pain Medicine
Pakistan - 1st Professional MBBS
Pakistan - 2nd Professional MBBS
Pakistan - 3rd Professional MBBS
Pakistan - 4th Professional MBBS
Pakistan - Final Professional MBBS
Pakistan FCPS Part I (Basic Science)
Pathology - Anatomic
Pathology - Blood Banking Transfusion Medicine
Pathology - Chemical
Pathology - Clinical
Pathology - Cytopathology
Pathology - Forensics
Pathology - Hematopathology
Pathology - Microbiology
Pathology - Molecular Genetic
Pathology - Neuropathology
Pathology - Pediatric
Pathophysiology - Nursing Student
Pediatric
Pediatric - Cardiology
Pediatric - Child Abuse
Pediatric - Critical Care
Pediatric - Developmental Behavioral
Pediatric - Emergency Medicine
Pediatric - Endocrinology
Pediatric - Gastroenterology
Pediatric - Hematology-Oncology
Pediatric - Hospital Medicine
Pediatric - Infectious Diseases
Pediatric - MRCPCH UK
Pediatric - Neonatal Perinatal
Pediatric - Nephrology
Pediatric - Neurology
Pediatric - Pulmonology
Pediatric - Rehabilitation Medicine
Pediatric - Rheumatology
Pediatric Advanced Life Support® (PALS®)
Pediatric Surgery
Pennsylvania State CME CE Requirements
Pharmacology PN - Nursing Student
Pharmacology RN - Nursing Student
Pharmacy - Ambulatory Care (BCACP®)
Pharmacy - Applied Toxicology (ABAT®)
Pharmacy - Cardiology (BCCP®)
Pharmacy - Certified Pharmacy Technician (PTCB® CPhT®)
Pharmacy - Critical Care (BCCCP®)
Pharmacy - Emergency Medicine (BCEMP®)
Pharmacy - Geriatric (BCGP®)
Pharmacy - Infectious Disease (BCIDP®)
Pharmacy - NAPLEX®
Pharmacy - Nutrition Support (BCNSP®)
Pharmacy - Oncology (BCOP®)
Pharmacy - Pediatric (BCPPS®)
Pharmacy - Pharmacotherapy (BCPS®)
Pharmacy - Psychiatric (BCPP®)
Physical Medicine and Rehabilitation
Physical Therapy - Geriatric Clinical Specialist (ABPTS® APTA® GCS)
Physical Therapy - Neurology Clinical Specialist (ABPTS® APTA® NCS)
Physical Therapy - Orthopedic Clinical Specialist (ABPTS® APTA® OCS)
Physical Therapy - Pediatric Clinical Specialist (ABPTS® APTA® PCS)
Physical Therapy - Physical Therapist (NPTE-PT)®
Physical Therapy - Physical Therapist Assistant (NPTE-PTA)®
Physical Therapy - Sports Clinical Specialist (ABPTS® APTA® SCS)
Plastic Surgery
Podiatry - APMLE® Part 1
Podiatry - APMLE® Part 2
Podiatry - APMLE® Part 3
Podiatry Foot and Ankle Surgery
Podiatry Medicine
Professional Ethics, Leadership, and Management - Nursing Student
Psychiatry
Psychiatry - Addiction
Psychiatry - Child and Adolescent
Psychiatry - Consultation-Liaison
Psychiatry - Forensic
Psychiatry - Geriatric
Psychology - Examination for Professional Practice In Psychology (EPPP®)
Psychology - Neuropsychology
Psychology - Psychopharmacology Examination (PEP®)
Public Health and General Preventive Medicine
Puerto Rico State CME CE Requirements
Pulmonary
Quality Board
Radiation Oncology
Radiologic Technologist - Magnetic Resonance Imaging (ARRT-MRI®)
Radiologic Technologist - Radiography (ARRT-R®)
Radiology - Breast
Radiology - Cardiac
Radiology - Diagnostic Radiology Qualifying (Core)
Radiology - Gastrointestinal
Radiology - Genitourinary
Radiology - Musculoskeletal
Radiology - Neuroradiology
Radiology - Pediatric
Radiology - Physics and Safety
Radiology - Thoracic
Radiology - Ultrasound
Radiology - Vascular and Interventional
Radiology Technology - Computed Tomography (ARRT-CT® or NMTCB-CT®)
Radiology Technology - Nuclear Medicine (ARRT® or NMTCB-CNMT®)
Radiology Technology - Vascular Interventional Radiography
Registered Cardiovascular Invasive Specialist (RCIS)®
Registered Dietitian (RD®) / Registered Dietitian Nutritionist (RDN®)
Respiratory Therapist - Certified or Registered (CRT® or RRT®)
Respiratory Therapy - Adult Critical Care Specialist (RRT-ACCS®)
Respiratory Therapy - Neonatal and Pediatric (RRT-NPS®)
Respiratory Therapy - Pulmonary Function Technologist (CPFT® or RPFT®)
Rheumatology
Rhode Island State CME CE Requirements
Sleep
Social Work - ASWB® Advanced Generalist
Social Work - ASWB® Bachelors and Associate
Social Work - ASWB® Clinical
Social Work - ASWB® Masters
Sonography - Cardiac Sonographer
Sonography - Registered Diagnostic Medical Sonographer® (RDMS-Ob/Gyn®)
Sonography - Registered Diagnostic Medical Sonographer®-Abdomen (RDMS-AB®)
Sonography - Vascular (ADRMS® RVT®, ARRT® VS®, CCI® RVS®)
South Carolina State CME CE Requirements
South Dakota State CME CE Requirements
Speech-Language Pathology Praxis® (SLP®)
SPEX®
Spinal Cord Injury Medicine
Spine Surgery
Sports Medicine
Surgical Critical Care
Tennessee State CME CE Requirements
Texas State CME CE Requirements
Thoracic Surgery
Toxicology
Transesophageal Echocardiography
Transplant Hepatology
UK - Medical Licensing Assessment (UKMLA/MLA)
UK - Multi-Specialty Recruitment Assessment (MSRA - CPS)
UK - Prescribing Safety Assessment (PSA)
UK Overseas Registration (ORE)
UK PLAB 1
Undersea and Hyperbaric
Urology
Urology - Pediatric
USMLE® Step 1
USMLE® Step 2
USMLE® Step 3
Utah State CME CE Requirements
Vascular Medicine (ABVMVascular Medicine (ABVM®)
Vascular Surgery
Venous, Lymphatic, and Phlebology Medicine
Vermont State CME CE Requirements
Virgin Islands State CME CE Requirements
Virginia State CME CE Requirements
Washington State CME CE Requirements
West Virginia State CME CE Requirements
Wisconsin State CME CE Requirements
Wound
Wyoming State CME CE Requirements

reCAPTCHA

Recaptcha requires verification.

I'm not a robot

reCAPTCHA

Create Account

Learn more about a Subscription to StatPearls Point-of-Care

Already have an account? Log in

Etiology

Gallstones are usually formed from bile that is in stasis. When bile is not fully emptied from the gallbladder, it can precipitate as sludge and subsequently turn into stones. Biliary obstruction may also lead to gallstones, including bile duct strictures and cancers, such as pancreatic cancer. The most common cause of cholelithiasis is the precipitation of cholesterol that subsequently forms into cholesterol stones. The second form of gallstones is pigmented gallstones, which result from increased red blood cell destruction in the intravascular system causing increased concentrations of bilirubin, which subsequently get stored in the bile. These stones are typically black. The third type of gallstones is mixed pigmented stones, a combination of calcium substrates such as calcium carbonate or calcium phosphate, cholesterol, and bile. The fourth type is made up primarily of calcium and is usually found in patients with hypercalcemia. When multiple gallstones or a singular large gallstone get impacted in Hartman's pouch (the lower outpouching of the gallbladder), external compression of the common bile duct or the common hepatic duct can occur. The exact mechanism as to why this occurs is unknown but appears to be related to a floppy Hartman's pouch containing a higher mass of stones, such as with multiple stones or a single large impacted stone. This causes subsequent inflammation of the are, which can also lead to fistula formation over time. [[2]](/content/point-of-care/25184#ref_29654105 ""/index.html)

Epidemiology

The epidemiology of gallstones must first be understood. Most gallstones are asymptomatic. In the United States, approximately 14 million men and 6 million women with an age range of 20 to 74 have gallstones. The prevalence increases as a person ages. Obesity increases the likelihood of gallstones, especially in women, due to increases in the biliary secretion of cholesterol. On the other hand, patients with drastic weight loss or fasting have a higher chance of gallstones secondary to biliary stasis. Furthermore, there is also a hormonal association with gallstones. Estrogen has been shown to result in an increase in bile cholesterol and a decrease in gallbladder contractility. Women of reproductive age or on birth control medication that have estrogen have a 2-fold increase in gallstone formation compared to males. People with chronic illnesses such as diabetes also have an increase in gallstone formation and reduced gallbladder wall contractility due to neuropathy.

Mirizzi syndrome is relatively uncommon. Only 0.1% of patients with gallstones will develop this condition, and it has been found in 0.7% to 25% of patients who have undergone cholecystectomies. There may be an increased occurrence in the older populations, but there has not been a predilection for either male or female patients with gallstones. There also appears to be no prevalence for any particular ethnic population. [[3]](/content/point-of-care/25184#ref_30159303 ""/index.html)

Pathophysiology

Gallstones occur when substances in the bile reach their limits of solubility. As bile becomes concentrated in the gallbladder, it becomes supersaturated with these substances, precipitating into small crystals in time. These crystals, in turn, become stuck in the gallbladder mucus, resulting in gallbladder sludge. Over time, these crystals grow and form large and/or multiple stones. These gallstones may cause cholecystitis symptoms, but if they become embedded in a floppy Hartman's pouch, they can cause additional findings of jaundice. As this condition progresses, internal fistulas from the gallbladder into the common bile duct, common hepatic duct (CHD), and the duodenum can develop. A grading system has been developed to categorize the various stages of Mirizzi syndrome.

Type I: No Fistula Present

Type IA: Presence of the cystic duct
Type IB: Obliteration of the cystic duct

Types II to IV: Fistula Present

Type II: Defect smaller than 33% of the CHD diameter
Type III: Defect 33% to 66% of the CHD diameter
Type IV: Defect larger than 66% of the CHD diameter [[4]](/content/point-of-care/25184#ref_30246584 ""/index.html)

Histopathology

Findings of acute or chronic cholecystitis can be found on histology. The gallbladder wall may be thickened to variable degrees, and there may be adhesions to the serosal surface. Smooth muscle hypertrophy, especially in prolonged chronic conditions, is present. Calcium bilirubinate or cholesterol stones are most often present and can vary in size from sand-like to filling the entire gallbladder lumen. They can be multiple or singular. The acalculous disease may reveal sludge or very viscous bile. These findings are usual precursors to gallstones and are formed from increased biliary salts or stasis. Normal appearing bile can also be present. Various species of bacteria can be found in 11% to 30% of the cases. Rokitansky-Aschoff sinuses are present 90% of the time in cholecystitis specimens. These are a herniation of intraluminal sinuses from increased pressures possibly associated with ducts of Luschka. The mucosa will exhibit varying degrees of inflammation.

There is an increased risk of developing gallbladder cancer with Mirizzi's syndrome. The exact etiology is unclear but is felt to be due to persistent and recurrent irritation of the area and chronic biliary stasis. 5% to 28% of patients with Mirizzi syndrome were found to have gallbladder cancer after cholecystectomy. Virtually all diagnoses were made postoperatively with pathologic examination of the specimens. [[5]](/content/point-of-care/25184#ref_28616794 ""/index.html)

History and Physical

The presentation of Mirizzi syndrome is usually that of acute or chronic cholecystitis with the addition of jaundice. Patients with chronic cholecystitis usually present with dull right upper abdominal pain that radiates to the mid back or right scapular tip. It is usually associated with fatty food ingestion. Nausea and occasional vomiting also accompany complaints of increased bloating and flatulence. Often the symptoms occur in the evening. Prolonged, less acute symptoms are usually present over weeks or months. Increased frequency and severeness of acute exacerbations (acute biliary colic) are usually seen in the presence of more prolonged chronic symptoms. The classic physical examination will demonstrate right upper abdominal pain with deep palpation (Murphy's sign). Patients are usually not acutely ill but are uncomfortable. Patients with advanced Mirizzi syndrome or more severe acute cholecystitis may present with more pronounced symptoms and findings. Jaundice is usually present, and at times, significantly elevated bilirubin can be identified. [[6]](/content/point-of-care/25184#ref_29372128 ""/index.html)

Evaluation

The routine workup for cholecystitis should be initiated. The best test for diagnosing gallstones and subsequent acute cholecystitis is a right upper quadrant abdominal ultrasound. It is associated with a 90% specificity rate and, depending on the ultrasound operator, can detect stones as small as 2 mm as well as sludge and gallbladder polyps. Ultrasound findings that point toward acute cholecystitis versus cholelithiasis include gallbladder wall thickening (greater than 3 mm), pericholecystic fluid, and a positive sonographic Murphy's sign. Gallstones can also often be found on CT scans and MRIs; however, these studies are not as sensitive for acute cholecystitis. Approximately 10% of gallstones may be found on routine plain films due to their high calcium content. Air in the biliary tree may also be detected on these radiographic studies if there is an enteric fistula present. If there is a suspected stone in the common bile duct based on ultrasound results, magnetic resonance cholangiopancreatography (MRCP) is the next step. If a common duct stone is identified on the MRCP, then the gold-standard test of an endoscopic retrograde cholangiopancreatogram (ERCP) should be performed by a gastroenterologist. A percutaneous transhepatic cholangiogram (PTHC) is also useful in diagnosing common bile duct stones if an ERCP is not possible. Usually, the diagnosis of Mirizzi syndrome is either mistaken for a simple common bile duct stone or is missed entirely on preoperative workup. [[7]](/content/point-of-care/25184#ref_28989998 ""/index.html)

Treatment / Management

The treatment for Mirizzi syndrome is cholecystectomy. Laparoscopic cholecystectomy is preferable, but a more involved surgery may be needed if the condition is advanced. An open cholecystectomy is an option. In cases of a more progressed disease, a partial cholecystectomy can be considered. This would involve leaving Hartman's pouch in place and removing the body of the gallbladder and the gallstones. This will lower the incidence of injury to the porta hepatis and bile ducts. If a fistula is present, then an open cholecystectomy with bilioenteric anastomosis, possibly with a Roux-n-Y, has been shown to be effective. [[8]](/content/point-of-care/25184#ref_27585469 ""/index.html) [[9]](/content/point-of-care/25184#ref_28210510 ""/index.html) [(B3)](/content/point-of-care/25184# ""/index.html)

Differential Diagnosis

Many other conditions can mimic gallbladder disease. Patients who present with acute biliary colic are often worked up for cardiac issues. Other common conditions with similar presenting symptoms are: [[8]](/content/point-of-care/25184#ref_27585469 ""/index.html)

Peptic ulcer disease
Irritable bowel disease
Inflammatory bowel disease
Gastroesophageal reflux disease
Pulmonary embolism

The presence of jaundice in combination with the other presenting symptoms in Mirizzi syndrome is usually mistaken for other etiologies such as:

Common bile duct stones
Ascending cholangitis
Biliary cancer
Pancreatic tumors

Other medical conditions to consider that may mimic Mirizzi syndrome include:

Acute hepatitis
Ischemic liver disease
Drug-induced hepatitis

Prognosis

In patients without fistula formation, the surgical repair and outcome are usually favorable. Due to the distorted anatomy and high rate of conversion to open cholecystectomy for this disease; however, some sources recommend an open surgical approach for all patients affected by Mirizzi syndrome. The prognosis for patients with fistula formation involves prolonged treatment with T-tube placement through the small-moderate sized fistula or biliary diversion with a choledochoduodenostomy or a Roux-en-Y choledochojejunostomy for larger fistulas. A prolonged surgical and hospital course for the latter group of patients increases their risk of complications and increases their morbidity and mortality rate. Gallbladder cancer has been associated with Mirizzi syndrome as well, although this is thought to be due to prolonged inflammation leading to both diseases, rather than a result of Mirizzi syndrome itself. [[10]](/content/point-of-care/25184#ref_16858544 ""/index.html) In elderly patients with multiple comorbidities and a high risk of surgical complications, nonoperative methods should be considered to minimize morbidity associated with the surgery. [[11]](/content/point-of-care/25184#ref_31467763 ""/index.html)

Complications

The most common complication of Mirizzi syndrome is cholecystobiliary or cholecysto-enteric fistula formation due to prolonged inflammation. Surgical complications with prolonged procedure time due to dense adhesions may also occur. These include bile duct injury and hemorrhage. Massive hemorrhage during dissection of the Calot triangle can occur in complex cases. Other complications of prolonged inflammation that can be seen in patients with Mirizzi syndrome include:

Cutaneous fistula formation
Secondary biliary cirrhosis
Delayed onset biliary strictures [[12]](/content/point-of-care/25184#ref_29369192 ""/index.html)

Deterrence and Patient Education

Patient education on medical compliance, clinical follow-up, and wound care is essential, especially in patients who required stent placement, biliary diversion, choledochoduodenostomy, or a Roux-en-Y choledochojejunostomy. Patients should be educated intensively on discharge and referred to wound care nursing if needed to prevent secondary infections and their associated complications.

Pearls and Other Issues

Mirizzi syndrome often is not diagnosed preoperatively. Awareness of this condition with the knowledge of appropriate treatment is essential. The surgeon must also entertain the possibility of the presence of occult gallbladder cancer.

Enhancing Healthcare Team Outcomes

An interprofessional team approach must be taken for this condition. This interprofessional healthcare team includes clinicians (MDs, DOs, NPs, and PAs), and nurses, coordinating their activities to achieve better patient outcomes.

Accurate diagnosis with an accurate evaluation of the extent of this disease must be concluded by all involved. The surgeon is the main specialist for diagnosis and treatment, but familiarity and a high degree of suspicion of this condition must be present by the initially treating primary caregiver or emergency physician. Delay in making an adequate diagnosis and treatment could lead to the progression of this condition with increased patient morbidity and mortality.

References

[1]

Bellamlih H, Bouimetarhan L, En-Nouali H, Amil T, Chouaib N, Jidane S, Rafai M, Belkouch A, Belyamani L. [Mirizzi's syndrome: a rare cause of biliary tract obstruction: about a case and review of the literature]. The Pan African medical journal. 2017:27():45. doi: 10.11604/pamj.2017.27.45.12469. Epub 2017 May 18 [PubMed PMID: 28819467]

Level 3 (low-level) evidence

[2]

Falk V, Low G, Bigam D, Sandha G. Acute acalculous cholecystitis of an intrahepatic gallbladder causing Mirizzi's syndrome. BMJ case reports. 2018 Apr 13:2018():. pii: bcr-2018-224365. doi: 10.1136/bcr-2018-224365. Epub 2018 Apr 13 [PubMed PMID: 29654105]

Level 3 (low-level) evidence

[3]

Clemente G, Tringali A, De Rose AM, Panettieri E, Murazio M, Nuzzo G, Giuliante F. Mirizzi Syndrome: Diagnosis and Management of a Challenging Biliary Disease. Canadian journal of gastroenterology & hepatology. 2018:2018():6962090. doi: 10.1155/2018/6962090. Epub 2018 Aug 12 [PubMed PMID: 30159303]

[4]

Zhou J, Xiao R, Yang JR, Wang L, Wang JX, Zhang Q, Ren JJ. Mirizzi syndrome complicated by common hepatic duct fistula and left hepatic atrophy: a case report. The Journal of international medical research. 2018 Nov:46(11):4806-4812. doi: 10.1177/0300060518797246. Epub 2018 Sep 23 [PubMed PMID: 30246584]

Level 3 (low-level) evidence

[5]

Kuga D, Ebata T, Yokoyama Y, Igami T, Sugawara G, Mizuno T, Yamaguchi J, Nagino M. Long-term survival after multidisciplinary therapy for residual gallbladder cancer with peritoneal dissemination: a case report. Surgical case reports. 2017 Dec:3(1):76. doi: 10.1186/s40792-017-0351-x. Epub 2017 Jun 14 [PubMed PMID: 28616794]

Level 3 (low-level) evidence

[6]

Pak S, Valencia D, Sheehy B, Agbim U, Askaroglu Y, Dee C. Ticking Bomb: Asymptomatic Mirizzi Syndrome. Cureus. 2017 Nov 16:9(11):e1854. doi: 10.7759/cureus.1854. Epub 2017 Nov 16 [PubMed PMID: 29372128]

[7]

Shirah BH, Shirah HA, Albeladi KB. Mirizzi syndrome: necessity for safe approach in dealing with diagnostic and treatment challenges. Annals of hepato-biliary-pancreatic surgery. 2017 Aug:21(3):122-130. doi: 10.14701/ahbps.2017.21.3.122. Epub 2017 Aug 31 [PubMed PMID: 28989998]

[8]

Kulkarni SS, Hotta M, Sher L, Selby RR, Parekh D, Buxbaum J, Stapfer M. Complicated gallstone disease: diagnosis and management of Mirizzi syndrome. Surgical endoscopy. 2017 May:31(5):2215-2222. doi: 10.1007/s00464-016-5219-9. Epub 2016 Sep 1 [PubMed PMID: 27585469]

[9]

Jones JD, Pawa R. Single-Operator Peroral Cholangioscopy for Extraction of Cystic Duct Stones in Postcholecystectomy Mirizzi Syndrome. Case reports in gastrointestinal medicine. 2017:2017():1710501. doi: 10.1155/2017/1710501. Epub 2017 Jan 22 [PubMed PMID: 28210510]

Level 3 (low-level) evidence

[10]

Prasad TL, Kumar A, Sikora SS, Saxena R, Kapoor VK. Mirizzi syndrome and gallbladder cancer. Journal of hepato-biliary-pancreatic surgery. 2006:13(4):323-6 [PubMed PMID: 16858544]

Level 2 (mid-level) evidence

[11]

Chai LF, Xiao GS. Choledochoplasty with Gallbladder Wall Free Flap: A Novel Technique for Large Bile Duct Defects from Mirizzi Syndrome in High-Risk Patients-A Case Report and Literature Review. Case reports in surgery. 2019:2019():4615484. doi: 10.1155/2019/4615484. Epub 2019 Jul 30 [PubMed PMID: 31467763]

Level 3 (low-level) evidence

[12]

Chen H, Siwo EA, Khu M, Tian Y. Current trends in the management of Mirizzi Syndrome: A review of literature. Medicine. 2018 Jan:97(4):e9691. doi: 10.1097/MD.0000000000009691. Epub [PubMed PMID: 29369192]

Copy link

✓

Thanks for sharing!

Find any service

AddToAny

[More…](/content/point-of-care/25184#addtoany "Show all"/index.html)

A2A

reCAPTCHA

Get aFree StatPearls Question-Of-The-Day

For Your Specialty.

Send IT