P0092 - Lemmel Syndrome: A Rare Cause of Obstructive Jaundice

Jiteshwar S. Pannu, MD¹, Michael Sutton, MD², John Maple, DO^1
1University of Oklahoma Health Sciences Center, Oklahoma City, OK; ²University of Oklahoma College of Medicine, Oklahoma City, OK

Introduction: Lemmel syndrome (LS) is a rare phenomenon manifesting as obstructive jaundice due to biliary compression by a periampullary duodenal diverticula (PDD), in the absence of other obstructing pathology. Due to its infrequent occurrence, it may be overlooked, yet can potentially lead to significant clinical morbidity. Herein, we present a patient diagnosed with obstructive jaundice due to periampullary diverticulitis i.e. LS, that was treated endoscopically.

Case Description/Methods: A 47-year-old female was admitted with epigastric abdominal pain, vomiting, jaundice and intermittent fevers. Physical exam revealed scleral icterus and epigastric tenderness. Pertinent labs included T. bilirubin 2.5 mg/dL, D. bilirubin 1.8 mg/dL, AST 352 U/L, ALT 483 U/L, ALP 955 IU/L, serum lipase 263. CT abdomen revealed a 4.3 X 2.5 cm inflamed duodenal diverticulum, causing extrinsic common bile duct (CBD) compression and biliary tree dilation. Given the CT findings and evidence of cholestasis, LS was considered as a possible cause of biliary obstruction. Patient subsequently underwent an ERCP that demonstrated a large PDD with an indwelling food bolus associated with mucosal ulceration. The food bolus was dislodged into the distal duodenum, followed by selective cannulation of the congested, intradiverticular papilla. Cholangiography demonstrated diffuse dilation of the CBD, without other obstructing pathology. A biliary sphincterotomy and papillary dilation were performed followed by placement of a CBD stent. After the ERCP, the patient improved clinically, coinciding with down trending liver biochemistries.

Discussion: The estimated prevalence of PDD ranges from 1%-27%, with only a minority (1%-5%) developing pancreaticobiliary complications. The mechanism of developing LS can be attributed to mechanical outflow obstruction due to the debris/enterolith filled PDD, fibrosis of the major papilla with sphincter of Oddi malfunction due to chronic inflammation or induction of primary choledocholithiasis from chronic biliary stasis and bacterial overgrowth. While diagnosis is aided by imaging modalities such as CT or MRCP, ERCP is considered as the gold standard for diagnostic and therapeutic interventions. Surgical interventions such as diverticulectomy and biliodigestive anastomosis are reserved for complicated or recurrent cases. Early recognition and treatment of LS, frequently with diverticular evacuation, biliary drainage and supportive medical care, is usually associated with favorable clinical outcomes.



Disclosures:


Jiteshwar S. Pannu, MD¹, Michael Sutton, MD², John Maple, DO¹. P0092 - Lemmel Syndrome: A Rare Cause of Obstructive Jaundice, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.