Diagnosis and Management of Lemmel Syndrome: An Unusual Presentation and Literature Review

Abstract

Lemmel syndrome is a rare clinical entity characterized by the presence of a periampullary duodenal diverticulum resulting in compression and dilatation of the pancreatic and common bile ducts, accompanied by obstructive jaundice. Gastric outlet obstruction is not a known complication of this syndrome, and there are no standardized approaches to its treatment. We present the first case of Lemmel syndrome presenting as gastric outlet obstruction and provide the results of a systematic literature review.

Keywords: Case report; Endoscopic retrograde cholangiopancreatography; Lemmel syndrome; Obstructive jaundice; Pancreas; Periampullary diverticulum.

Fig. 1.

CT abdomen pelvis demonstrating a 2.7 × 3.7 × 5.2 cm complex pancreatic head lesion containing air and debris (a), contiguous with the duodenum at the junction of the second and third segments (b) with moderate 1.0 cm dilatation of the common bile duct (c) and 0.6 cm dilatation of the main pancreatic duct (d, e). CT abdomen pelvis demonstrating GOO manifested as markedly distended stomach with distal gastric and proximal duodenal wall thickening and hyperenhancement (f).

Fig. 2.

Endoscopic ultrasonography (EUS) demonstrating common and biliary ductal dilation in the setting of an otherwise endosonographically normal pancreas.

Fig. 3.

Large non-bleeding periampullary diverticulum in the second portion of the duodenum containing a large amount of food debris prior to lavage (a), during partial clearance (b), and following complete clearance (c).

Fig. 4.

CT abdomen pelvis demonstrating improvement in common bile duct dilation (a) and diverticular size with resolution of radiographic evidence of GOO (b, c) 10 days after endoscopic diverticular lavage. Bile duct measuring 0.7 cm, previously 1.0 cm. Diverticular dimensions measuring 1.9 × 3.6 × 3.7 cm (AP by transverse by craniocaudal), previously 2.7 × 3.7 × 5.2 cm. Pancreatic duct not visualized well likely due to resolution of dilation following removal of diverticular contents.

Fig. 5.

Flow diagram of the literature search.