A Rare Case of Perimpullary Duodenal Diverticulitis Diagnosed by ERCP Causing Obstructive Jaundice (Lemmelʼs Syndrome)

Abstract

Background Periampullary duodenal diverticulum (PAD) is a common finding in ERCP. Duodenal diverticulitis is rare and can result in pancreatico-biliary complications. Lemmel's syndrome is a rare complication of periampullary diverticulum that results in obstructive jaundice in absence of stones or malignancy. In our case, duodenal diverticulitis lead to biliary obstruction, and was diagnosed at the time of ERCP. Case report The patient is a 66-year-old woman with a history of migraine, osteoarthritis, rheumatoid arthritis and prior cholecystectomy 17 years ago who presented with epigastric and right upper quadrant abdominal pain radiating to the back with associated nausea, vomiting and diarrhea after she had an undercooked meal. Initial work up revealed leukocytosis of 16,000 with no fever. Transaminases and bilirubin were normal initially. CT abdomen showed non-obstructive bowel gas pattern, post operative cholecystectomy with secondary CBD dilation and a 3.6x4.5 cm periampullary diverticulum without signs of inflammation. Two days later she developed fever, acute rise in transaminases and bilirubin (AST 524 IU/L, ALT 767 IU/L, T. bilirubin 6 mg/dl). She was started on IV Zosyn with fluid resuscitation. MRI/MRCP showed mild to moderate intra and extrahepatic dilation with tapering of distal CBD (13 mm) without stones or signs of diverticulitis. She subsequently underwent ERCP that showed duodenal diverticulitis causing obstruction of the adjacent ampulla and distal bile duct. Pancreatic and CBD stents were inserted. Repeat review of the prior MRI/MRCP confirmed duodenal diverticular inflammation that was not initially appreciated. The patient's fever and symptoms resolved after the ERCP and with antibiotics. Follow up ERCP after 6 weeks showed scarring down of the PAD opening and resolution of bile duct stricture. Discussion Periampullary duodenal diverticulum are located within 3 cm from the ampulla of Vater and found in 10-20% of patients undergoing ERCP. PAD may be associated with CBD stones, acute pancreatitis and can lead to difficult cannulation during ERCP. Lemmel's syndrome is a rare complication from PAD in which obstructive jaundice occurs secondary to compression from the PAD. Duodenal diverticulitis is very rare and usually diagnosed with CT scan in most of cases. In our case, it was diagnosed at the time of ERCP.1380_A.tif Figure 1: Pancreatic duct stent with diverticulum1380_B.tif Figure 2: Duodenal diverticulitis1380_C.tif Figure 3: Follow up ERCP