A giant duodenal diverticulum causing Lemmel syndrome

Lemmel's Syndrome: A Report of Two Cases at the Hospital General Dr. Manuel Gea Gonzalez in Mexico City

The term ¨Lemmel Syndrome¨ is used to describe obstructive jaundice that is secondary to periampullary duodenal diverticula (PDD) in the absence of choledocholithiasis or neoplasia. PDD is found in 22% of the population. According to our knowledge, only two cases of Lemmel syndrome have been reported in Mexico. We report two cases of Lemmel syndrome in a 94-year-old and a 71-year-old woman who presented with clinical jaundice. One of the cases was treated with endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy, balloon sweep, and the placement of a plastic biliary prosthesis, and the other with laparoscopic biliodigestive bypass and a manual lateral end choledocho-duodenal anastomosis. Our objective is to expand the information on this rare pathology to take it into account as a diagnostic possibility of jaundice and to define appropriate management, which can be endoscopic or surgical.

Lemmel's Syndrome: A Rare Complication of Periampullary Diverticula

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.

Lemmel syndrome: an unusual cause of biliary obstruction secondary to a duodenal juxta-ampullary diverticulum: a report of two cases

Lemmel's syndrome is a rare cause of obstructive jaundice caused by a periampullary duodenal diverticulum compressing the intrapancreatic common bile duct with resultant bile duct dilatation, patients with Lemmel's syndrome usually present with abdominal pain or jaundice. Cross-sectional imaging is beneficial in making the diagnosis noninvasively, thus eliminating other pathologies of the peri-ampullary region. Although rare, we recognize the importance of considering this syndrome to be able to make a diagnosis and offer timely treatment. We present 2 cases of Lemmel's syndrome whose diagnosis is retained based on a CT scan and magnetic resonance cholangiopancreatography.

A Rare Presentation of Duodenal Diverticulum Causing Obstructive Jaundice: Lemmel's Syndrome

Lemmel syndrome is an uncommon pancreaticobiliary consequence of duodenal diverticula. We herein present a case of an 80-year-old male who presented with upper abdominal discomfort. Based on lab values and relevant clinical history, a diagnosis of obstructive jaundice was made. A contrast-enhanced CT scan of the abdomen revealed gross dilatation of intra-hepatic and extra-hepatic bile duct, cystic duct, common bile duct, major and minor pancreatic duct. A contrast-filled outpouching was seen from the medial wall of the second part of the duodenum with duodenal diverticulum and papilla within it. The abrupt termination of the common bile duct and main pancreatic duct adjacent to the thickened wall of the diverticulum was the cause of the patient's pancreaticobiliary obstruction. In the absence of cholelithiasis or tumor, the duodenal diverticulum that manifests as obstructive jaundice is known as Lemmel syndrome. Prompt identification of Lemmel syndrome can avoid dangerous complications and unnecessary investigations. Gallstones, cholangitis, and bile duct stones are more common in patients with duodenal diverticula. Treatment depends on patient presentation and may involve conservative management, surgical procedures in the form of excision of the diverticulum, or even endoscopic sphincterotomy or stenting.

Síndrome biliar obstructivo no litiásico o de Lemmel ¿Es tan infrecuente como parece?

Introducción. Aproximadamente el 5 % de los divertículos duodenales pueden causar síntomas y el 1 % presentar complicaciones, siendo la colangitis la más frecuente. El síndrome de Lemmel corresponde a un tipo de ictericia obstructiva intermitente, asociado a la presencia de divertículos periampulares y disfunción del esfínter de Oddi, sin presencia de coledocolitiasis. Método. Se realizó una revisión sistemática de la literatura en Pubmed, Google Académico y ProQuest, con los términos: síndrome de Lemmel, divertículo duodenal sintomático e ictericia obstructiva intermitente. Resultados. Se encontraron 38 casos, siendo España el país con mayor número, seguido de México, Japón y Colombia. No hay diferencias de distribución con respecto al género. El tratamiento más frecuentemente empleado fue la colangio pancreatografia retrógrada endoscópica. Conclusión. El síndrome de Lemmel es poco frecuente, sin un cuadro clínico especifico, con un incremento en los casos informados en los últimos años, posiblemente debido a la mejor disponibilidad de métodos diagnósticos. Es más frecuente en pacientes en la octava década de la vida y su tratamiento generalmente es endoscópico.

Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study

BACKGROUND

Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association.

METHODS

We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors.

RESULTS

Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01).

CONCLUSION

We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.

Giant duodenal diverticulum masquerading as a sealed perforation

Giant duodenal diverticula are large outpouchings involving all layers of the duodenal wall. Whilst often an incidental finding, giant duodenal diverticula can present with diverticulitis or biliary obstruction. We report a case of a giant duodenal diverticulum that was initially misdiagnosed as a localised duodenal perforation on CT. Additional ultrasound and fluoroscopic imaging demonstrated the final diagnosis of acute cholecystitis. The clinical course of this patient highlights the challenge of recognising a giant duodenal diverticulum and the limitations of solely relying on CT in the context of an acute abdominal presentation.

Lemmel syndrome: an extraordinary cause of obstructive jaundice-a case report

Lemmel syndrome is created by a periampullary duodenal diverticulum. It is identified incidentally in 22% of the population, <10% present with jaundice, pain in the right flank and alteration of bilirubins, transaminases and/or pancreatic enzymes. Its diagnosis and therapeutic management can be carried out successfully with endoscopic retrograde cholangiopancreatography (ERCP), although some cases will require surgical management. We present the case of a 72-year-old male with recurrent obstructive jaundice and suspected choledocholithiasis managed with ERCP, identifying Lemmel syndrome. We recognize the importance of considering this extraordinary cause of obstructive jaundice in order to be able to make a diagnosis and offer timely treatment.

Lemmel’s syndrome: Presentation of an uncommon cholangitis cause and a risk factor for failed endoscopic retrograde cholangiopancreatography. Case report

Introduction

Lemmel's syndrome is a rare pathology that presents jaundice or dilation of common biliary tract, secondary to duodenal diverticula. Due to infrequency, a high suspicion has to be considered to avoid omitting this diagnosis, mainly in patients who present direct hyperbilirubinemia without choledocholithiasis.

Presentation of case

A 76-year-old female admitted to the emergency department with cholangitis, secondary to an ampullary diverticulum (papilla was located inside the diverticulum). As a consequence, the endoscopic retrograde cholangiopancreatography failed and a biliodigestive derivation (choledochal duodenum anastomosis) was performed.

Discussion and conclusions

This case is an example of an unusual clinical and anatomical presentation of duodenal diverticulum. This unusual presentation is an example of the importance of not overlooking a diagnosis, which can lead to more severe complications such as cholangitis. It is also important to consider that cases like this are risk factors for failed endoscopic management and surgical possibilities procedures should also be considered in the management.

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Unusual clinical and anatomical presentation of duodenal diverticulosis

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Risk factors for failed endoscopic retrograde cholangiopancreatography

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Uncommon cholangitis cause, and direct hyperbilirubinemia without choledocholithiasis

Lemmel's Syndrome Secondary to Common Bile Duct Compression by an Inflamed Duodenal Diverticulum

A 50-year-old female presented with acute epigastric abdominal pain, diarrhea, nausea, and vomiting for two days. Laboratory data showed hyperbilirubinemia and leukocytosis. Abdominal imagining was concerning for a pancreatic head/uncinate process lesion concerning a pancreatic neoplasm. Subsequent esophagogastroduodenoscopy with endoscopic ultrasound and endoscopic retrograde cholangiopancreatography found the major papilla adjacent to an inflamed and infected duodenal diverticulum, which was extrinsically compressing the distal common bile duct, causing biliary obstruction and common bile duct dilation. These findings are consistent with a diagnosis of Lemmel’s syndrome. A biliary sphincterotomy was performed to relieve the obstruction and one temporary plastic biliary stent was placed into the common bile duct. The duodenal diverticulitis was treated with antibiotics for 10 days and the patient made a good recovery.

Small bowel diverticulitis - Spectrum of CT findings and review of the literature

PURPOSE

To review the CT findings and complications of small bowel diverticulitis (SBD) and discuss clinical presentations and outcomes.

METHODS

A text search of radiology reports within our health system for cases of small bowel diverticulitis yielded 95 cases. All cases were reviewed by an abdominal radiologist with equivocal cases reviewed by a second abdominal radiologist for consensus. Retrospective analysis of CT imaging findings was performed on 67 convincing cases of SBD.

RESULTS

Small bowel diverticulitis most often affected the jejunum (58%) and the duodenum (26%). The most common imaging feature was peridiverticular inflammation manifested by peridiverticular edema, diverticular wall thickening, bowel wall thickening, and fascial thickening. Edema was typically seen along the mesenteric border of the bowel with relative sparing of the anti-mesenteric side. When a prior CT was available, the affected diverticulum was identified in 95% of cases. Fecalized content within the affected diverticulum was observed in 51% of cases. Perforation (6%) and abscess (6%) were the most common complications.

CONCLUSION

Small bowel diverticulitis is an uncommon cause of abdominal pain which can mimic an array of abdominal pathologies, although the reported mortality rate of 40-50% may no longer be accurate. The "fecalized diverticulum" sign can be helpful in identifying the culprit diverticulum and aid diagnosing SBD. Findings of perforation and or abscess formation are critical as they may impact management.

An unusual cause of obstructive jaundice: Lemmel's syndrome

Lemmel’s syndrome is a rare and misdiagnosed cause of obstructive jaundice. The cause of the obstacle is a duodenal diverticulum located at the periampullary generating a compression effect on the common bile duct with secondary dilation of the extra- and intra-hepatic bile ducts. Late diagnosis of this entity is common and may lead to unnecessary further investigations and therapeutic delay. There are only few case reports of this rare condition. We report a case of 77-year-old female presenting with obstructive jaundice due to Lemmel’s syndrome. The diagnosis was made on a set of clinical, biological and radiological arguments with good improvement after medical treatment.

Lemmel syndrome: an uncommon complication of periampular duodenal diverticulum

Lemmel's syndrome consists of obstructive jaundice due to compression of a periampular duodenal diverticulum (DDP), in the absence of choledocholithiasis or tumor. DDP are pseudodiverticula without a muscle layer within a radius of 2-3 centimeters from the ampulla of Vater. They rarely cause obstructive jaundice, although the prevalence is estimated at up to 22 % according to the sensitivity of the diagnostic test. They are usually incidental findings, but up to 1-5 % can be complicated with diverticulitis, bleeding, perforation, obstructive jaundice (Lemmel syndrome), choledocholithiasis, pancreatitis or cholangitis.

Lemmel's Syndrome: Usual Presentation of an Unusual Diagnosis

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.

Small Bowel Diverticulosis: Pathogenesis, Clinical Management, and New Concepts

PURPOSE OF REVIEW

Small bowel diverticulosis is a well-known clinical entity whose diagnosis and management has evolved in recent years. This review covers pathophysiology, incidence, and prevalence, and it also provides an update on modern diagnosis and management. Meckel's diverticula are covered elsewhere in this volume.

RECENT FINDINGS

CT scan and MRI have largely supplanted barium follow-through for diagnosis. No intervention is needed in asymptomatic individuals. Endoscopic management is playing an increasing role for both bleeding and resection of intraduodenal diverticula, but surgical intervention remains the only definitive intervention for other complications like diverticulitis and small bowel obstruction. Small bowel diverticulosis is an uncommon condition which is associated with numerous possible complications. While endoscopy is playing an increasingly large role in management, surgical resection remains the treatment of choice for most complications. A high index of suspicion is needed in order to diagnose this entity.