Case 265: Lemmel Syndrome or Biliary Obstruction Due to a Periampullary Duodenal Diverticulum

Venkatanarasimha, Nanda; Yong, Yan Rong; Gogna, Apoorva; Tan, Bien Soo

doi:10.1148/radiol.2019162375

Cited by 21 publications

(28 citation statements)

References 9 publications

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“…In most cases, laboratory workup reveals leukocytosis, elevated inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein, elevated direct and total bilirubin, elevated liver enzymes, elevated alkaline phosphatase, and elevated gamma-glutamyl transferase. Elevated pancreatic enzyme levels could be seen with compression of the ampulla of Vater by a PAD [9].…”

Section: Discussionmentioning

confidence: 99%

Lemmel’s Syndrome: Usual Presentation of an Unusual Diagnosis

Bernshteyn¹,

Rao²,

Sharma³

et al. 2020

Cureus

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Lemmel's syndrome causes obstructive jaundice in the absence of stones or tumors. The most common cause is the presence of periampullary diverticula which arise within 2-3 cm from the ampulla of Vater. Diverticula may be extramural or intramural. Despite current practice of obtaining imaging studies such as ultrasound, CT, and MRI, endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard diagnostic test. Lemmel's syndrome should be considered when pancreaticobiliary disease is suspected. We present a case in which our patient presented with abdominal pain, fever, and transaminitis who underwent ERCP which was successful in diagnosis of Lemmel's syndrome and its treatment. Although rare, it is imperative for physicians to recognize this syndrome in order to deliver prompt care.

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Section: Discussionmentioning

confidence: 99%

Lemmel’s Syndrome: Usual Presentation of an Unusual Diagnosis

Bernshteyn¹,

Rao²,

Sharma³

et al. 2020

Cureus

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“…3 Its physiopathology isn't certain and specific, but reported mechanisms include 3 mains causes, all due to the proximity of the diverticulum to the ampulla, either causing direct external compression of the common bile duct/ampulla leading to obstruction; or causing a dysfunction of the sphincter of Oddi; or causing direct irritation of the ampulla leading to its chronic inflammation and eventually fibrosis of the papilla. [4][5][6][7] These periampullary duodenal diverticula are often asymptomatic but they may become symptomatic in only 1% to 2% of the cases causing acute abdominal pain and simulating a biliopancreatic colic by an extrinsic obstruction of common bile duct or pancreatic duct. 8 They can also cause complications in 5% of the cases including 6 : This syndrome is only considered and retained in the absence of choledocholithiasis or any other etiology of obstructive jaundice.…”

Section: Discussionmentioning

confidence: 99%

“…Its physiopathology isn’t certain and specific, but reported mechanisms include 3 mains causes, all due to the proximity of the diverticulum to the ampulla, either causing direct external compression of the common bile duct/ampulla leading to obstruction; or causing a dysfunction of the sphincter of Oddi; or causing direct irritation of the ampulla leading to its chronic inflammation and eventually fibrosis of the papilla. 4 - 7 …”

Section: Discussionmentioning

confidence: 99%

“…Enhanced contrasted CT and MRCP allow better characterization of the lesion especially when it is filled with fluid, compared to its differential diagnosis: pancreatic abscess, pancreatic pseudo-cyst, pancreatic head cystic neoplasm, or a metastatic lymph node. 4,7,8 Endoscopic retrograde cholangiopancreatography allows a direct visualization of the diverticulum. 5 As PAD are usually asymptomatic, treatment is only required when the patient becomes symptomatic, and endoscopic treatment, such as, papillary balloon dilatation or endoscopic sphincterotomy with biliary stent placement represents the treatment of choice, showing a good success rate; however, recurrence rate stays high.…”

Section: Aourarh Et Almentioning

confidence: 99%

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An Unusual Cause of Biliary Tract Obstruction: Lemmel Syndrome

Aourarh

Tamzaourte

Benhamdane

et al. 2021

Clin Med Insights Case Rep

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Background: Lemmel syndrome is a rare and misdiagnosed etiology of obstructive jaundice due to a periampullary duodenal diverticulum causing a mechanical obstruction of the common bile duct. It represents an obstructive jaundice with the absence of choledocholithiasis or pancreaticobiliary tumors. It is an underreported entity due to the absence of specific pathognomonic signs. Case presentation: A 77-year-old-woman admitted for sepsis, due to an ascending cholangitis, underwent a MRCP and a gastroduodenoscopy revealing Lemmel’s syndrome. Due to failure of ERCP, the patient underwent surgical derivation. Conclusion: Lemmel syndrome represents an uncommon diagnosis of obstructive jaundice, that shouldn’t be neglected if no other organic cause is detected. It is usually asymptomatic, however some patients can develop symptoms and complications such as cholangitis, as is the case of our patient. Imaging allows diagnosis, with MRCP as the modality of choice to confirm diagnosis. Endoscopy is the first line treatment.

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“…Around 1-5% of cases only present with diverticular complications such as obstruction, diverticulitis, hemorrhage, and perforation [3]. The diagnosis is reached by imaging modalities such as abdominal ultrasound (US), barium studies, CT scan, esophagogastroduodenoscopy (EGD), and magnetic resonance cholangiopancreatography (MRCP) [2][3][4][5][6]. Conservative management is the mainstay of care in these patients by endoscopic retrograde cholangiography (ERCP) with sphincterotomy and stent placement [4,5,[7][8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Lemmel Syndrome as a Rare Cause of Prolonged Right Hypochondrial Pain: A Case Report

Azzam¹,

Alsinan²,

Alrebeh³

et al. 2021

Cureus

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Lemmel syndrome is a rare cholestatic disease caused by a periampullary duodenal diverticulum (PAD) compressing the common bile duct (CBD) or pancreatic duct, which results in acute abdominal pain and/or obstructive jaundice in the absence of other pathology explaining the symptoms. It can be easily misdiagnosed unless carefully detected by abdominal ultrasound (US), barium studies, computed tomography (CT) scan, esophagogastroduodenoscopy (EGD), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiography (ERCP), which is also the treatment modality of choice. We herein report a case of a 62-year-old male presenting with prolonged hypochondrial pain. He was diagnosed with Lemmel syndrome after performing US, barium meal, CT scan, EGD, and MRCP that was managed successfully by ERCP with sphincterotomy and stent placement.

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Case 265: Lemmel Syndrome or Biliary Obstruction Due to a Periampullary Duodenal Diverticulum

Abstract: years after initial percutaneous transhepatic cholangiography during a routine percutaneous biliary drainage catheter change showed the contrast-opacified periampullary duodenal diverticulum, which had markedly decreased in size and had no filling defect (Fig 3).

Cited by 21 publications

References 9 publications

Lemmel’s Syndrome: Usual Presentation of an Unusual Diagnosis

Lemmel’s Syndrome: Usual Presentation of an Unusual Diagnosis

An Unusual Cause of Biliary Tract Obstruction: Lemmel Syndrome

Lemmel Syndrome as a Rare Cause of Prolonged Right Hypochondrial Pain: A Case Report

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