LEMMEL SYNDROME – RARE CAUSE OF CHOLANGITIS : A CASE REPORT

Abstract

Introduction: Lemmel Syndrome is a rare cause of the biliary mechanical compression by the juxtapapillary pseudo-diverticulum, in the absence of gallstones or periampullary tumors. Most periampullary diverticula are asymptomatic. However, complications may occur in about 5%, including diverticulitis, pancreatitis, cholangitis, choledocholithiasis, enterolith, bezoar formation, intestinal obstruction, bleeding and perforation. Case report: A 60-year-old woman presented with abdominal pain,fever and jaundice of acute onset. She was hemodynamically stable except for a fever of 101 °F. Initial blood work revealed a WBC 14,500/mm3, ALT 118 IU/L, AST 189 IU/L, ALP 356 IU/L, T bilirubin 7.2 mg/dl. CT and MRI of abdomen revealed periampullary diverticulum compressing distal common bile duct causing proximal dilatation consistent with Lemmel syndrome. Patient was managed with broad spectrum antibiotics and other supportive measures in view of cholangitis. Patient underwent ERCP with CBD stenting. Patient’s lab parameters improved steadily and was asymptomatic in few days. Discussion: Our patient had abdominal pain associated with leukocytosis and cholangitis due to extrinsic compression of the distal CBD. Lemmel syndrome can be transient in nature as a result of a periampullary duodenal diverticulum causing extrinsic compression of the CBD. This can sometimes progress to cholangitis, as seen in our patient. Early diagnosis is necessary to avoid extensive and invasive workup. Management is often supportive, although in some cases with recurrent infection or persistent biliary obstruction, surgical diverticulectomy can be considered. Conclusion: Lemmel syndrome should be kept as a rare differential when evaluating patients with biliary obstruction.