Lemmel syndrome – An unusual cause of obstructive jaundice.

Clinical History

A 64-year-old woman presented to our hospital with several weeks of intermittent jaundice and mild epigastrial tenderness. Physical examination was unremarkable. Laboratory examinations revealed elevated bilirubin profile that suggested obstructive jaundice.

Imaging Findings

An abdominal contrast-enhanced Computed Tomography (CT) scan demonstrated a gas and fluid-filled duodenal diverticulum (3 cm) arising from the medial wall of the second portion of the duodenum. It is associated with lateral compression of distal third of the common bile duct causing common bile duct dilatation (11 mm) resulting in obstructive jaundice.
No lithiasis was present in the common bile duct nor other obstructive endoluminal or extraluminal causes such as tumour.
There was obvious compression of the common biliary tract by focal outpouching of the duodenum, thus confirming the diagnosis of Lemmel's syndrome.

Discussion

The duodenum is the second most common location for gastrointestinal diverticula. Duodenum diverticula are frequent (5-10%) and most are asymptomatic, except those that are located close to the ampulla of Vater such as periampullary diverticula [1, 2].
Most duodenal diverticula are acquired and typically occur in the periampullary region, along the medial aspect of the second portion of the duodenum. They are easily recognized on upper gastrointestinal barium examinations or on CT scan. Duodenal diverticula typically contain gas. However, diverticula are sometimes filled with fluid and can be mistaken for a pancreatic pseudocyst, pancreatic abscess or even cystic neoplasm in the head of the pancreas. [3]
Patients with choledolithiasis are 2.6 times more likely to have periampullary diverticula than those without. [4]
A duodenal diverticulum can present as pseudotumour, diverticulitis, enterolith or bezoar formation, intestinal obstruction, perforation, bleeding, cholangitis, pancreatitis or jaundice without common bile duct endoluminal obstruction also known as Lemmel's syndrome. [5]

Lemmel’s syndrome was first described in 1934 and refers to a duodenal diverticulum, typically on the second portion of the duodenum compressing the distal third of the common bile duct, resulting in biliary tree dilatation in the absence of lithiasis or other detectable obstructive cause.
The diagnosis of Lemmel's syndrome is typically done by CT scan, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography (MRCP). Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography are useful to confirm the diagnosis, exclude other possible causes such as choledocolithiasis and tumours and allow performing an endoscopic sphincterotomy to release the common bile duct obstruction.
Surgical treatment of asymptomatic diverticulum is not justified. Recourse to surgical management (diverticulectomy or biliodigestive anastomosis) would be necessary in selected cases where other conservative treatments have failed. [6]

Lemmel’s syndrome should always be included in the differential diagnosis of obstructive jaundice when periampullary diverticula are present in order to avoid mismanagement and therapeutic delay.

Differential Diagnosis List

Final Diagnosis

Lemmel syndrome (duodenal diverticulum causing obstructive jaundice)

URL:	https://eurorad.org/case/13148
DOI:	10.1594/EURORAD/CASE.13148
ISSN:	1563-4086