A rare pancreaticobiliary complication of duodenal diverticula is Lemmel syndrome. Lemmel syndrome is defined as an obstructive jaundice. ABSTRACT. In Lemmel was the first to report the presence of juxtapapillary diverticula and hepatocholangiopancreatic disease, excluding cholelithiasis. Lemmel’s syndrome, juxtapapillary diverticula, periampullary duodenal In Lemmel was the first to report the presence of juxtapapillary.
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Although PAD usually do not cause symptoms, it can serve as a source of obstructive jaundice even when choledocholithiasis or tumor is not present. This duodenal diverticulum obstructive sydnrome syndrome is called Lemmel’s syndrome.
An yr-old woman came to the emergency room with obstructive jaundice and cholangitis.
Lemmel Syndrome Secondary to Duodenal Diverticulitis: A Case Report
ERCP was performed to remove the stone. After removal of the enterolith within the PAD, all her symptoms resolved. Recognition of this condition is important since misdiagnosis could lead to mismanagement and therapeutic delay. Lemmel’s syndrome should always be included as one of the differential diagnosis of obstructive jaundice when PAD are present.
Periampullary diverticula PAD refer to extraluminal outpouchings of duodenal mucosa that develop within the radius of 2 to 3 cm from the ampulla of Vater 1. PAD are largely asymptomatic but they sometimes can cause both pancreaticobiliary and non-pancreaticobiliary complications. Rarely, obstructive jaundice can develop secondary to PAD in the absence of choledocholithiasis or tumor and is termed Lemmel’s syndrome 2. Ysndrome, the authors experienced an unusual xyndrome of abdominal pain and obstructive jaundice due to extrinsic compression of mid common bile duct CBD by distended PAD filled with pus-like material as a result of impacted intradiverticular enterolith at the PAD orifice.
Herein, we report a case Lemmel’s syndrome that was successfully managed endoscopically. An yr-old woman presented to the emergency department on August 3, with nausea, vomiting, fever She had undergone subtotal gastrectomy with billroth II anastomosis due to peptic ulcer perforation 10 yr ago.
On physical examination, there was tenderness oemmel her right upper quadrant but Murphy’s sign was equivocal. The results of her liver function test were as follows: To evaluate the cause of diffuse pemmel pain with liver enzyme elevation in a cholestatic pattern, abdominal CT scan was taken. However, on lememl reconstructed images, the stone was not located within the bile duct but inside the PAD and the distended diverticulum was compressing the mid CBD Fig.
These findings were confirmed on endoscopic retrograde cholangiopancreatography ERCP which showed normal biliary orifice Fig. When the enterolith was pushed into the diverticulum by cannulation catheter and contrast dye was injected Fig. Biliary cannulation combined with endoscopic sphincterotomy EST was also performed to explore the CBD for other possible causes of obstructive jaundice but no stone, stricture or syndrkme by tumor could be found.
After confirming syndromd no other pathology was present, intradiverticular enterolith was crushed and removed by Dormia basket on the following day Fig.
Lemmel syndrome | Radiology Reference Article |
After the procedure, the patient no longer complained of abdominal pain, her liver enzyme was normalized, and she was discharged without any complication. On axial CT scan, a high attenuated stone density with internal air black arrow is seen on distal common bile duct CBD A.
However, coronal reconstructed image shows that the stone black arrow is not located in the CBD but within the periampullary diverticulum that is filled with air and debris along with mid CBD stricture white arrow B.
This finding is depicted in line art to better delineate the anatomical relationship C. Endoscopic retrograde cholangiopancreatographic findings of enterolith eyndrome the periampullary diverticulum PAD and its pemmel. When dye is injected into the PAD, an ovoid shaped filling defect white arrow can be seen A. Endoscopic nasobiliary drainage tubogram obtained after lemmle of the PAD demonstrates resolved extrinsic compression B.
After completion of enterolith removal, filling defect is no longer seen within the PAD C. She had been well until 6 months after enterolith removal, when the patient visited the outpatient clinic with vague abdominal discomfort. Laboratory examination only revealed slightly increased total bilirubin to 1. When the CBD stone was removed by ERCP, the synrome proved xyndrome be brown pigment sludge stone that typically forms in the presence of ascending infection Fig.
PAD at this time was neither distended nor filled with enterolith. She remains clinically and radiographically disease free after the last procedure. Removal of common bile duct CBD stone. Follow-up computed tomography scan taken about sundrome months after enterolith removal shows an ovoid stone white arrow within the CBD A.
Diverticula of the gastrointestinal tract are outpouchings lrmmel all or part of the intestinal wall which can occur anywhere throughout the alimentary tract. The most common site of gastrointestinal diverticula is colon followed by duodenum, which was first described by Chomel in 3.
Among these complications, hepatocholangiopancreatic disease can seldomly occur in the absence of choledocholithiasis and is termed Lemmel’s syndrome 2. Pathologic mechanisms through which Lemmel’s syndrome is thought to occur include the following. First, diverticulitis or direct mechanical irritation of PAD may cause chronic inflammation syndrone ampulla and lead to chronic fibrosis of papilla papillitis chronica fibrosa 4.
Second, PAD many cause dysfunction in the sphincter of Oddi 5.
Third, distal CBD or ampulla can be directly compressed mechanically by PAD that is usually filled with enterolith or bezoar 67. This obstruction combined with inflammation of the diverticulum and collection of pus-like material within the obstructed PAD seems to have expanded the PAD with resultant extrinsic compression of mid Sgndrome Fig.
This was quite different from previous cases in which compression occurred at distal CBD. PAD normally have a relatively wide orifice. Therefore, the enterolith, bezoar, or food material within the PAD is frequently evacuated and thus, the symptom could be intermittent. However, PAD in our case had a narrow opening, likely due to repeated inflammation of the PAD, and this seems to have hindered the clearance synddrome entrapped enterolith out into the duodenal lumen.
Enterolith syndrone within the duodenal diverticula is known to be facilitated in the static environment such as a blind loop after gastrectomy or proximal portion of stricture formed by Crohn’s disease or tuberculosis 8. In our case, blind loop created by Billroth II anastomosis seems to have provided a static environment favoring enterolith formation lemmeo the PAD.
During enterolith removal, CBD was also explored to search for other possible source of obstructive jaundice such as CBD stone since primary biliary stone is known to occur more frequently in the presence of PAD 9 Although CBD was explored in our case, no other etiology of obstructive jaundice could be identified other than extrinsic compression by distended PAD.
The most plausible explanation is that EST performed during CBD exploration at the time of enterolith removal has permitted the occurrence of ascending infection with resultant brown pigment stone formation. Diagnosing Lemmel’s syndrome could be challenging, but lemmmel aware of this condition is important to avoid mismanagement and lemnel begins with identification of PAD.
However, PAD are sometimes filled with fluid and can frequently be mistaken for pancreatic pseudocyst, pancreatic abscess, cystic neoplasm in the pancreas head or even metastatic lymph node 12 Therefore, high index of suspicion is mandatory to arrive at a correct diagnosis in these patients.
In our case, enterolith within the PAD on axial images was at first mistaken for distal CBD stone due to its distal location combined with upstream dilatation of the bile duct Fig. However, upon careful scrutinization of the coronal reconstructed images, it became ayndrome that the stone was located within the PAD Syndrpme. Treatment is generally not recommended in asymptomatic patients or would be conservative management in pauci-symptomatic patients.
Nevertheless, since most patients with Lemmel’s syndrome present with symptoms related to biliary obstruction i. Therapeutic options in this situation run the gamut from endoscopic extraction of entrapped material, extracorporeal shock wave lithotripsy to surgery diverticulectomy or biliodigestive anastomosis 714 The patient in our case was also successfully treated endoscopically by fragmenting and removing enterolith using a Dormia basket.
If the underlying mechanism of Lemmel’s syndrome is likely to be due to papillitis chronica fibrosa or sphincter of Oddi dysfunction as mentioned above, the simplest and the most appropriate management would be to perform EST In conclusion, Lemmel’s syndrome is a rare cause of obstructive jaundice that should be included in the differential diagnosis of biliary obstruction when PAD is present.
Maintaining a high index of suspicion is imperative to establish an accurate diagnosis since it can mimic other cystic or solid lesions around the pancreas head.
Lemmel Syndrome Secondary to Duodenal Diverticulitis: A Case Report
Symptomatic patient can be successfully managed endoscopically in many instances but recourse to surgical management would be necessary in selected cases.
National Center for Biotechnology InformationU. J Korean Med Sci. Published online May Find articles stndrome Hyo Sung Kang. Find articles by Jong Jin Hyun.
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Find articles by Hyung Joon Yim. Find articles by Sang Woo Lee. Author information Article notes Copyright and License information Disclaimer. Jong Jin Hyun, MD. Received Oct 5; Accepted Dec This article has been cited by other articles in PMC. Open in a separate window. Enterolith, Lemmel’s Syndrome, Periampullary Diverticulitis.
Periampullary diverticula and pancreaticobiliary disease. Die Klinische Bedeutung der Duodenal Divertikel. Report of a case of duodenal diverticulum containing gallstones. Histoire Acad R Sci Paris. Manabe T, Yu GS. Duodenal diverticulum causing intermittent-persistent cholestasis: N Y State J Med.
Tomita R, Tanjoh K. Endoscopic manometry of the sphincter of Oddi in patients with Lemmel’s syndrome. Lemmel’s syndrome as a rare cause of obstructive jaundice. Clin Res Hepatol Gastroenterol. A case of Lemmel’s syndrome caused by a large diverticular enterolith at the peripapillary portion of the duodenum. Nihon Ronen Igakkai Zasshi.
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