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

摘要

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 class="unordered" style="list-style-type:disc">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. class="kwd-title">Keywords: Lemmel’s syndrome, juxtapapillary diverticula, periampullary duodenal diverticulum (PAD), choledocholithiasis, cholelithiasis, ERCP, MRCP, ampulla of Vater, pancreaticobiliary class="head no_bottom_margin" id="__sec2title">INTRODUCTIONLemmel’s syndrome is defined as obstructive jaundice caused by periampullary duodenal diverticulum (PAD) in absence of choledocholithiasis or tumor. A duodenal diverticulum is a sac-like out-pouching of the duodenal mucosa. Duodenal diverticula are mostly asymptomatic and found incidentally in up to 22% of the population, out of which less than 10% are symptomatic.These are categorized into extramural and intramural diverticula, the majority of which are extra-luminal. Extra-luminal duodenal diverticulum (EDD) is a herniation acquired from a defect in the bowel wall due to entrance of vessels. Intramural duodenal diverticulum (IDD) is a rare congenital anomaly resulting from incomplete canalization of the lumen. Clinicians should always consider diverticulum as a possible cause of pancreatitis and obstructive jaundice ^[–].