Lemmel's Syndrome: A Rare Cause of Obstructive Jaundice Secondary to Periampullary Diverticulum

Abstract

In 1934 Lemmel was the first to report the presence of juxtapapillary diverticula and hepatocholangiopancreatic disease, excluding cholelithiasis. Obstructive jaundice caused by periampullary duodenal diverticulum (PAD) in absence of choledocholithiasis or tumor is known as Lemmel syndrome. A patient with an extraluminal duodenal diverticulum presenting with obstructive jaundice and pancreatitis is presented in this case. Although initially managed conservatively, the patient had recurrence of symptoms after 2 months but then had successful surgical resection of the duodenal diverticulum.

Learning points: Lemmel's syndrome should be considered in patients with pancreaticobiliary disease in the absence of tumors, stricture, or cholelithiasis.Non-invasive imaging studies should be considered first but endoscopic retrograde cholangiopancreatography (ERCP) remains the diagnostic method of choice.Surgical resection (diverticulectomy), endoscopic sphincterotomy, and papillary balloon dilatation are treatment options when conservative management fails.

Keywords: ERCP; Lemmel’s syndrome; MRCP; ampulla of Vater; choledocholithiasis; cholelithiasis; juxtapapillary diverticula; pancreaticobiliary; periampullary duodenal diverticulum (PAD).

Figure 1

CT scan demonstrating diffuse stranding around the pancreatic head and adjacent duodenum

Figure 2

MRCP showing a 1.1 cm ovoid cystic lesion adjacent to the descending duodenum consistent with a duodenal diverticulum