Lemmel's Syndrome: A Rare Complication of Periampullary Diverticula

Abstract

Periampullary diverticula are outpouches in the mucosa in the duodenum surrounding the ampulla of Vater. Most cases of periampullary diverticuli are asymptomatic, but complications can arise, increasing a patient's mortality. Diagnosis of periampullary diverticuli is often incidental during endoscopy or imaging studies for abdominal pain. When a patient with periampullary diverticuli is symptomatic, imaging modalities such as CT scan and MRI can help make the diagnosis, but a side-viewing endoscope provides direct visualization of the diverticuli and also allows for the potential treatment of the disease. Lemmel's syndrome is a complication of periampullary diverticuli where the diverticuli causes mechanical obstruction of the bile duct leading to obstructive jaundice without choledocholithiasis. These patients are at risk for further complications such as sepsis and perforation. Early diagnosis and treatment of these patients can help to prevent further complications from arising. We are presenting a case of Lemmel's syndrome with obstructive jaundice from a periampullary diverticuli, further complicated by cholangitis without dilation of the biliary tree.

Keywords: acute cholangitis; cholangitis; endoscopy; lemmel's syndrome; obstructive jaundice; periampullary diverticula; periampullary diverticulum.

Figure 1. CT of the abdomen and pelvis without contrast showed a diverticulum at the ampulla of Vater (red arrow).

Figure 2. Upper endoscopy showing major papilla in the descending duodenum was located entirely within a large diverticulum.

Figure 3. Endoscopic retrograde cholangiopancreatography (ERCP) revealed the major papilla in the descending duodenum was located entirely within a large diverticulum. A 0.035 x 260 cm straight Hydra Jagwire® was placed into the biliary tree, and one Advanix® Biliary 7 Fr by 7 cm plastic stent was placed into the common bile duct.