Lemmel syndrome: the role of prudent radiological evaluation - a case report

Lemmel syndrome (LS) is a rare cause of obstructive jaundice resulting from compression of the distal common bile duct (CBD) by a periampullary duodenal diverticulum. The diagnosis is frequently missed due to nonspecific clinical features and subtle radiologic findings.

A 39-year-old woman presented with recurrent epigastric pain, fever, and jaundice. Laboratory results showed leukocytosis and elevated bilirubin levels. Ultrasonography and magnetic resonance cholangiopancreatography (MRCP) demonstrated gallstones with mild biliary dilatation and suspected CBD sludge, prompting a laparoscopic cholecystectomy with planned CBD exploration. Intraoperative findings revealed a normal cystic duct and no evidence of obstruction. Re-evaluation of the MRCP during surgery identified an air pocket adjacent to the distal CBD, suggesting a periampullary diverticulum. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) confirmed LS caused by food debris within the diverticulum. Endoscopic balloon sweep and sphincterotomy achieved complete resolution, and the patient remained symptom-free at 6 months.

The case highlights a diagnostic pitfall, which is an over-reliance on radiologists' interpretations and printed MRCP images. Review of thin-slice digital MRCP images by the surgical team could have revealed the diverticulum earlier. Hospitals with infrastructure that allows simultaneous endolaparoscopic procedures offer optimal workflow and outcomes.

Careful review of preoperative imaging, multidisciplinary coordination, and the availability of intraoperative ERCP are crucial for the accurate diagnosis and effective management of LS, preventing unnecessary bile duct exploration and reducing morbidity.