A 74-year old female patient presented with abrupt epigastric pain, vomiting and jaundice. Laboratory tests revealed an elevated total bilirubin of 4.85 mg/dL (direct 4.12 mg/dL). Abdominal ultrasound showed several calculi in the gallbladder and an increased diameter of intra-hepatic and common biliary duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) was not possible due to failed cannulation (Fig. 1), even using a pre-cut technique, however duodenoscopy identified a large periampullary duodenal diverticulum, with food debris.
An endoscopic ultrasound (EUS) was performed (Fig. 2 and 3).
Endoscopic ultrasound showed a compressed distal CBD by a periampullary diverticulum. The diagnosis of Lemmel syndrome was assumed. Considering the resolution of symptoms and laboratorial normalization after food removal, no other treatment was performed. After 8 months no recurrence was observed.
Periampullary diverticula (PAD) are not uncommon findings in patients undergoing ERCP. Although many of PAD are asymptomatic, some may be associated with pancreatobiliary disease [1,2]. Lemmel syndrome, originally described by Gerhard Lemmel, is a symptom complex defined by the presence of obstructive jaundice caused by a periampullary duodenal diverticulum . Although it is a rare condition, it should be considered as a differential diagnosis in the absence of choledocholithiasis, strictures or tumors [3,4,5].
Margarida Flor de Lima1, Nuno Nunes1, Carolina Chálim Rebelo1, Ana Catarina Rego1, Maria Antónia Duarte1