Zainab Abbasi, MD, Ange Ahoussougbemey Mele, MD, Daniel Castresana, MD, Alison Moe, PA-C Northeast Georgia Medical Center, Gainesville, GA
Introduction: Lemmel's syndrome is a rare condition that results in obstructive jaundice, most commonly from a periampullary duodenal diverticulum. They typically cause the sphincter of Oddi to malfunction or manually impede the common bile duct's (CBD) outflow. It is crucial to have a high index of suspicion to establish correct diagnosis, as this syndrome can imitate several benign and malignant abnormalities in the periampullary region. We report a preeminent case of Lemmel’s syndrome successfully treated with ERCP.
Case Description/Methods: A 52-year-old female with a medical history of diabetes and cholecystectomy who presented with worsening upper abdominal for two days, with nausea and poor oral intake. On exam, she was tachycardic and had poorly localized upper abdominal tenderness. Labs revealed WBC of 24.7 k/mm3, AST of 174 U/L, ALT 263 U/L, ALP of 361 U/L, total bilirubin of 4.3 mg/dL, and lipase of 2814. CT scan revealed diffuse stranding around the pancreatic head and duodenitis. MRCP confirmed a narrowing along the pancreatic head, a duodenal diverticulum and CBD was dilated without choledocholithiasis. She underwent ERCP, which revealed a 2 cm ulcerated periampullary diverticulum causing distal CBD obstruction. Moreover, pus was noted oozing from the diverticulum concerning for diverticulitis. Cholangiogram showed distal tapering CBD stricture with upstream biliary ductal dilation. A biliary sphincterotomy was performed with multiple sweeps with no stone, and stent was placed. Post procedure patient had improvement in her symptoms and liver chemistries.
Discussion: Lemmel’s syndrome is a periampullary duodenal diverticulum (PAD) leading to obstructive jaundice. PAD typically forms 2-3 cm away from the ampulla of Vater. It is a rare entity with prevalence of 0.16-27%, based on the imaging diagnostic modality used. Most patients are asymptomatic. Pancreaticobiliary cases and non-pancreaticobiliary cases can both be categorized. A CT scan and MRCP can support the diagnosis. However, the gold standard for diagnosis is a side-viewing endoscope used during ERCP that can show a thin-walled cavitary lesion in the second half of the duodenum. It is advised to use a conservative approach for asymptomatic patients. Most individuals who report biliary obstruction or cholangitis symptoms may benefit from ERCP, extracorporeal shockwave lithotripsy, or surgery like diverticulectomy. An endoscopic sphincterotomy is preferred if sphincter of Oddi dysfunction is causing Lemmel's syndrome, as in this patient.
Figure: Periampullary diverticulum oozing pus seen during ERCP
Zainab Abbasi indicated no relevant financial relationships.
Ange Ahoussougbemey Mele indicated no relevant financial relationships.
Daniel Castresana indicated no relevant financial relationships.
Alison Moe indicated no relevant financial relationships.
Zainab Abbasi, MD, Ange Ahoussougbemey Mele, MD, Daniel Castresana, MD, Alison Moe, PA-C. P2960 - A Preeminent Cause of Acute Biliary Pancreatitis: Lemmel's Syndrome, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.