Pokharel Selene, Gurung Ram B, Khadka Saurav, Shrestha Sneha, Upadhyaya Prashant
Department of Internal Medicine, Kathmandu University School of Medical Sciences.
Department of Surgery, Kathmandu University School of Medical Sciences.
Ann Med Surg (Lond). 2024 Sep 30;86(12):7347-7350. doi: 10.1097/MS9.0000000000002622. eCollection 2024 Dec.
One of the very rare causes of obstructive jaundice, Lemmel's syndrome, is caused due to biliary mechanical compression by a juxtapapillary diverticulum. It is defined as obstructive jaundice due to juxtapapillary diverticulum in the absence of cholelithiasis, periampullary tumours, or other detectable obstacles. It is an extremely rare syndrome; therefore, studies need to be done for proper diagnosis and management.
Our patient, a 73-year-old woman, gave a history of recent acute right hypochondriac pain that had subsided the day before. Lab investigations were performed and liver enzymes were found to be significantly raised. An endoscopy followed by an endoscopic ultrasound was performed for further diagnosis, which showed the diverticulum outpouching from the duodenum. MRCP was then performed, which revealed a dilated common bile duct and common hepatic duct, with tapering at the distal end, most likely to be a stricture. Lemmel syndrome was identified based on the clinical presentation and imaging results. A dilated common bile duct, and two large duodenal diverticula with interdiverticular papilla was discovered during the patient's endoscopic ultrasound, which was performed by the gastrointestinal team.
Duodenal diverticula are the second most common site of diverticula after the colon with an incidence of 1-5% in radiological series. Lemmel's syndrome is a rare cause of obstructive jaundice associated with juxtapapillary diverticulum. With a low incidence rate, only a few cases of Lemmel's syndrome are reported with the first case reported in 1934 by Lemmel. Imaging techniques such as barium meal, EUS, ERCP, or magnetic resonance cholangiopancreatography are used to confirm the diagnosis. Our observations demonstrate that the diverticulum, which is often found on the medial wall of the second half of the duodenum and contains bezoar, compresses the distal common bile duct laterally. Nowadays, ERCP and EUS are used to confirm the diagnosis. Only symptomatic periampullary duodenal diverticulum (PDD) requires conservative or surgical therapy. The first line of treatment for biliopancreatic PDD problems is endoscopic sphincterotomy, which is 95% effective.
Lemmel syndrome occurs due to the compression of the common bile duct by a duodenal diverticulum. Imaging, including CT scans, and MRCP are important for the diagnosis of this syndrome. Treatment modalities are not the same for each patient, however.
Lemmel综合征是梗阻性黄疸极为罕见的病因之一，由十二指肠乳头旁憩室对胆管的机械性压迫所致。它被定义为在无胆结石、壶腹周围肿瘤或其他可检测到的梗阻因素情况下，因十二指肠乳头旁憩室引起的梗阻性黄疸。这是一种极其罕见的综合征；因此，需要开展研究以进行正确的诊断和管理。
我们的患者是一名73岁女性，有近期急性右季肋部疼痛病史，疼痛已于前一天缓解。进行了实验室检查，发现肝酶显著升高。随后进行了内镜检查及内镜超声检查以进一步诊断，结果显示憩室自十二指肠突出。接着进行了磁共振胰胆管造影（MRCP），结果显示胆总管和肝总管扩张，远端逐渐变细，很可能是狭窄。根据临床表现和影像学结果确诊为Lemmel综合征。在患者的内镜超声检查过程中，胃肠病团队发现了扩张的胆总管以及两个带有憩室间乳头的十二指肠大憩室。
十二指肠憩室是仅次于结肠的第二大常见憩室部位，在放射学系列研究中的发生率为1% - 5%。Lemmel综合征是与十二指肠乳头旁憩室相关的梗阻性黄疸的罕见病因。由于发病率低，自1934年Lemmel首次报告该病例以来，仅有少数Lemmel综合征病例被报道。钡餐、内镜超声（EUS）、内镜逆行胰胆管造影（ERCP）或磁共振胰胆管造影等影像学技术用于确诊。我们的观察表明，憩室常位于十二指肠后半部的内侧壁且含有胃石，会从侧面压迫胆总管远端。如今，ERCP和EUS用于确诊。仅出现症状的壶腹周围十二指肠憩室（PDD）需要保守或手术治疗。胆胰PDD问题的一线治疗方法是内镜括约肌切开术，其有效率为95%。
Lemmel综合征是由于十二指肠憩室压迫胆总管所致。包括CT扫描和MRCP在内的影像学检查对该综合征的诊断很重要。然而，每位患者的治疗方式并不相同。
