1362 A Rare Case of Obstructive Jaundice and Acute Pancreatitis

Abstract

INTRODUCTION: Gallstones is the most common cause of both biliary pancreatitis and obstructive jaundice. Rarely, periampullary diverticula (PAD) and choledochal cysts can present with the same symptomatology. PAD is usually asymptomatic, but complications can occur in about 5% of cases. Among these, Lemmel's syndrome defined as obstructive jaundice in absence of choledocholithiasis or neoplasm and pancreatitis have been rarely reported. Choledochal cysts are abnormal dilatations of the biliary tree with type III (choledochocele) being the least common subtype, representing <5% of reported cysts. Pancreatitis is the most common clinical complication and is normally the inciting event that leads to identification of the choledochocele. We present a case of recurrent pancreatitis and obstructive jaundice secondary to Lemmel's syndrome and choledochocele. CASE DESCRIPTION/METHODS: Case of a 60-year-old male with history on uncomplicated pancreatitis, who presented with nausea, vomiting, epigastric pain and fever of 2 days of duration. Physical examination with diffuse abdominal tenderness. Laboratories with leukocytosis, alkaline phosphatase 202 U/L, total bilirubin 8.3 mg/L, lipase 700 U/L and amylase 1089 U/L. Abdominopelvic CT showed acute pancreatitis, no cholelithiasis or biliary tree dilation. Magnetic resonance cholangiopancreatography showed duodenal diverticulum and choledochocele. Endoscopic retrograde cholangiopancreatography revealed a large diverticuli next to the ampulla with debris and sacular appearance of the intraduodenal portion of the common bile duct (CBD) as seen in choledochocele. The pancreatic duct was normal. A pre-cut sphincterotomy was performed. There was normalization of laboratories for which he was discharge home. DISCUSSION: Lemmel's syndrome is caused by a periampullary duodenal diverticula causing extrinsic compression of the CBD and preventing secretion of the bile. In choledochocele, there is a dilatation of the intramural portion of the distal CBD within the duodenal wall. Both diagnoses should be included in the differential of benign biliary obstruction or pancreatitis when PAD or cyst are present in imaging. In both cases, symptomatic patients can be approach with sphincterotomy. As in our case, the patient had no further episode of pancreatitis or obstructive jaundice after successful sphincterotomy. Maintaining a high index of suspicion is required to establish an accurate diagnosis since they can mimic other cystic or solid lesions around the pancreas head.