A 74-year old female patient presented with abrupt epigastric pain, vomiting and jaundice. Laboratory tests revealed an elevated total bilirubin of 4.85 mg/dL (direct 4.12 mg/dL). Abdominal ultrasound showed several calculi in the gallbladder and an increased diameter of intra-hepatic and common biliary duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) was not possible due to failed cannulation (Fig. 1), even using a pre-cut technique, however duodenoscopy identified a large periampullary duodenal diverticulum, with food debris.
An endoscopic ultrasound (EUS) was performed (Fig. 2 and 3).
What is the most likely diagnosis?
Endoscopic ultrasound showed a compressed distal CBD by a periampullary diverticulum. The diagnosis of Lemmel syndrome was assumed. Considering the resolution of symptoms and laboratorial normalization after food removal, no other treatment was performed. After 8 months no recurrence was observed.
Periampullary diverticula (PAD) are not uncommon findings in patients undergoing ERCP. Although many of PAD are asymptomatic, some may be associated with pancreatobiliary disease [1,2]. Lemmel syndrome, originally described by Gerhard Lemmel, is a symptom complex defined by the presence of obstructive jaundice caused by a periampullary duodenal diverticulum . Although it is a rare condition, it should be considered as a differential diagnosis in the absence of choledocholithiasis, strictures or tumors [3,4,5].
- Zoepf T, Zoepf D, Arnold J, Benz C, Riemann J. The relationship between juxtapapillary duodenal diverticula and disorders of the biliopancreatic system: analysis of 350 patients. Gastrointest Endosc 2001;54:56–61.
- Egawa N, Anjiki H, Takuma K, Kamisawa T. Juxtapapillary duodenal diverticula and pancreatobiliary disease. Dig Surg. 2010;27(2):105-9.
- Lemmel G. The clinical significance of the duodenal diverticulum (Die klinische Bedeutung der Duodenaldivertikel). Digestion 1934;56:59–70.
- Tobin R, Barry N, Foley NM, Cooke F. A giant duodenal diverticulum causing Lemmel syndrome. J Surg Case Rep. 2018(10):rjy263.
- Desai K, Wermers J, Beteselassie N. Lemmel syndrome secondary to duodenal diverticulitis: a case report. Cureus 2017;9:e1066.
Margarida Flor de Lima1, Nuno Nunes1, Carolina Chálim Rebelo1, Ana Catarina Rego1, Maria Antónia Duarte1
- Gastroenterology Department, Hospital do Divino Espírito Santo de Ponta Delgada