Lemmel's syndrome

A 57-year-old man with previous cholecystectomy presented with a 5-day history of abdominal pain and jaundice. He did not have a fever. Physical examination revealed pain in the right upper quadrant of the abdomen, rebound was absent; Murphy's sign was negative. Laboratory results included a white-cell count 10.25 × 10⁹, with 82% neutrophils, liver panel was: total bilirubin 5.84 mg/dL (conjugated bilirubin 4.8 mg/dL), alkaline phosphatase 218 U/L, gamma-glutamyl transferase 340 U/L, aspartate aminotransferase 197 U/L, aspartate aminotransferase 321 U/L. Abdominal ultrasonography was normal and contrast magnetic resonance imaging (MRI) scan (Fig. 1) showed no intrahepatic or extrahepatic biliary dilatation and presence of a large juxtapapillary diverticulum. He was treated with broad-spectrum antibiotic therapy and discharged after one week. At one-year follow-up, the patient was asymptomatic.

Figure 1.

Abdominal T2-MRI scan. T2-contrast magnetic resonance imaging (MRI): a large juxtapapillary diverticulum (arrow) without intrahepatic or extrahepatic biliary dilatation.

Periampullary diverticula are usually asymptomatic; however, complications can occasionally occur,¹ including diverticulitis, duodenal obstruction, perforation, hemorrhage, acute pancreatitis,² or biliary symptoms.

Lemmel's syndrome is a rare cause of obstructive jaundice in the absence of gallstones and periampullary tumors, due to biliary mechanical compression by a juxtapapillary diverticulum. There are only few case reports of this rare condition.^1,3 This entity can associate with abdominal pain or acute cholangitis mimicking periampullary tumors, and can be recurrent. In relatively asymptomatic patients, conservative treatment is recommended. In some cases endoscopic treatment can be used by means of sphincterotomy,¹ requiring surgical management if biliary obstruction is present or symptoms are often recurrent.³

Conflicts of interest

The authors declare no conflicts of interest. The patient has signed the informed consent and has agreed to the use and publication of the confidential information and images with a scientific purpose and without a lucrative objective. All authors have read and approved the paper submitted.