Zeyn Mirza, MD1, Carlos Fernández, MD2, Francisco Tirado, MD1, Jose Martin-Ortiz, MD, FACG1
1VA Caribbean Healthcare System, San Juan, Puerto Rico; 2Hospital de Veteranos (VA Caribbean Healthcare System), San Juan, Puerto Rico
Introduction: Obstructive jaundice can be caused by intraluminal forces (choledocholithiasis), extraluminal forces (carcinoma) or transmural forces (choledochal cysts). In addition to the above, a rare cause of obstructive jaundice includes periampullary diverticula - Lemmel’s syndrome. This syndrome involves a periampullary duodenal diverticulum that can compress the common bile duct resulting in obstructive jaundice. These diverticula are extraluminal and their prevalence increases with age and given that the majority are asymptomatic, they can be overlooked in imaging studies. It is estimated that 5% of patients experience acute symptomatology due to these diverticula.
Case Description/Methods: This is the case of an over 90-year-old male with medical history of hypertension and Alzheimer’s dementia who came to the ER due to right upper quadrant abdominal pain the day prior to admission. Physical wasexam remarkable for epigastric and right upper quadrant tenderness. Labs with transaminitis (ALT:1294 U/L, AST: 1166 U/L), alkaline phosphatase 366 U/L, total bilirubin 3.2 mg/dL, amylase: 123 U/L, lipase: 98 U/L). Abd/pelvic CT scan reported prominence of the intrahepatic and extrahepatic biliary system. The common bile duct measuring 8-9 mm, proximal pancreatic duct dilated approximately 4 mm, and the common bile duct extending to a large duodenal diverticulum without evidence of choledocholithiasis. Considering the patients advanced age, he was treated with conservative medical management including antibiotic therapy.
Discussion: This case highlights the importance of taking a holistic approach to patient care especially patients of advanced age who may have findings suggestive of a diagnosis that is overlooked as it is uncommon. The literature states that the detection rate of duodenal diverticula ranges from 1% to 27%. In addition, the majority of peri-ampullar diverticula are asymptomatic however 5% of cases can present with bleeding, jaundice or intestinal obstruction. Misdiagnosis of this condition may lead to erroneous management and delay in treatment in patients who are able to receive aggressive management.
Citation: Zeyn Mirza, MD; Carlos Fernández, MD; Francisco Tirado, MD; Jose Martin-Ortiz, MD, FACG. P0100 - LEMMEL SYNDROME IN A CENTENARIAN. Program No. P0100. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.