J Korean Med Sci.  2014 Jun;29(6):874-878. 10.3346/jkms.2014.29.6.874.

Lemmel's Syndrome, an Unusual Cause of Abdominal Pain and Jaundice by Impacted Intradiverticular Enterolith: Case Report

• Kang HS
• Hyun JJ
• Kim SY
• Jung SW
• Koo JS
• Yim HJ
• Lee SW

• KMID: 1796954
• DOI: http://doi.org/10.3346/jkms.2014.29.6.874

Abstract

Duodenal diverticula are detected in up to 27% of patients undergoing upper gastrointestinal tract evaluation with periampullary diverticula (PAD) being the most common type. Although PAD usually do not cause symptoms, it can serve as a source of obstructive jaundice even when choledocholithiasis or tumor is not present. This duodenal diverticulum obstructive jaundice syndrome is called Lemmel's syndrome. An 81-yr-old woman came to the emergency room with obstructive jaundice and cholangitis. Abdominal CT scan revealed stony opacity on distal CBD with CBD dilatation. ERCP was performed to remove the stone. However, the stone was not located in the CBD but rather inside the PAD. After removal of the enterolith within the PAD, all her symptoms resolved. Recognition of this condition is important since misdiagnosis could lead to mismanagement and therapeutic delay. Lemmel's syndrome should always be included as one of the differential diagnosis of obstructive jaundice when PAD are present.

Keyword

Enterolith; Lemmel's Syndrome; Periampullary Diverticulitis

MeSH Terms

Abdominal Pain
Aged, 80 and over
Cholangiopancreatography, Endoscopic Retrograde
Cholangiopancreatography, Magnetic Resonance
Cholangitis/complications
Diverticulum
Duodenal Diseases/complications/*diagnosis
Female
Fluoroscopy
Gallstones/diagnosis/therapy
Humans
Jaundice, Obstructive/*complications
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) findings of the biliary tract. On axial CT scan, a high attenuated stone density with internal air (black arrow) is seen on distal common bile duct (CBD) (A). However, coronal reconstructed image shows that the stone (black arrow) is not located in the CBD but within the periampullary diverticulum that is filled with air and debris along with mid CBD stricture (white arrow) (B). This finding is depicted in line art to better delineate the anatomical relationship (C). Absence of CBD stone and mid CBD stricture is also demonstrated on MRCP image (D).

• 

  Fig. 2 Endoscopic retrograde cholangiopancreatographic findings of enterolith within the periampullary diverticulum (PAD) and its removal. A dark brown pigment stone (white arrow) is seen impacted at the orifice of the PAD (A, B). When the stone is pushed upward into the PAD (C), old blood clots is seen gushing out from the PAD orifice (D). The enterolith within the PAD is being fragmented and removed with Dormia basket (E, F).

• 

  Fig. 3 Fluoroscopic images. When dye is injected into the PAD, an ovoid shaped filling defect (white arrow) can be seen (A). Endoscopic nasobiliary drainage tubogram obtained after decompression of the PAD demonstrates resolved extrinsic compression (B). After completion of enterolith removal, filling defect is no longer seen within the PAD (C).

• 

  Fig. 4 Removal of common bile duct (CBD) stone. Follow-up computed tomography scan taken about 6 months after enterolith removal shows an ovoid stone (white arrow) within the CBD (A). CBD stone (white arrow) removed by Dormia basket (B) proved to be brown pigment sludge stone (C).

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