Lemmel Syndrome: A Case Report

Lemmel syndrome is a rare and misdiagnosed cause of obstructive jaundice due to a periampullary duodenal diverticulum (PAD) in the absence of choledocholithiasis or a tumor. PADs are extraluminal outpouchings of duodenal mucosa that develop within a radius of 2-3 cm from the ampulla of Vater. They are largely asymptomatic, but rarely they can cause acute abdominal pain and obstructive jaundice due to the extrinsic compression of the common bile duct or pancreatic duct. PADs are mostly asymptomatic, but complications can occur, such as hemorrhage, perforation, diverticulitis, pancreatitis, choledocholithiasis, cholangitis, jaundice, or intestinal obstruction. Treatment workup depends on the clinical presentation. The authors present the clinical case of an 84-year-old woman who presented to the emergency department with jaundice, refusal to feed, vomiting, and prostration with a two-day duration. On physical examination, jaundice and tenderness in the upper quadrants were observed. Blood tests revealed anemia, leukocytosis with neutrophilia, and elevated aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, and gamma-glutamyl transferase. Abdominal computed tomography showed ectasia of the intra-hepatic bile ducts and main bile duct, compressed extrinsically by a PAD. Due to the patient's previous functional status, conservative management was decided.