S1416 A Not so Simple Case of Obstructive Jaundice

Abstract

INTRODUCTION: Lemmel syndrome is a rare cause of obstructive jaundice caused by a duodenal diverticulum compressing the intra-pancreatic part of the common bile duct with resultant dilation of the extra-and intrahepatic bile ducts. In our case, we present a patient with suspected Lemmel syndrome after a difficult diagnostic workup, demonstrating the importance of a broad differential when approaching jaundice. CASE DESCRIPTION/METHODS: We present a 50-year-old Caucasian male with a history of EtOH abuse, necrotizing pancreatitis s/p laparoscopic cystogastrostomy, obesity, and cholecystectomy. The patient presented with a four-day history of sharp, epigastric pain associated with nausea, non-bloody vomiting, and lethargy. The patient stated the symptoms were similar to those related to prior episodes of necrotizing pancreatitis and admitted to drinking 16 cans of beer per day for the past four months. Physical examination revealed diffuse jaundice, scleral icterus, and right upper quadrant tenderness. Initial laboratory findings included platelets 86 × 109/L., total bilirubin 13.52 mg/ dL, AST 900 U/L, ALT 266 U/L, ALP 456 U/L and GGT 11180 U/L. Right upper quadrant ultrasound noted patent portal and hepatic veins. Magnetic resonance cholangiopancreatography (MRCP) was performed. It noted a 1.7 cm mildly high T1 lesion medial and contiguous with the second portion of the duodenum, possibly representing a duodenal diverticulum. The common bile duct was dilated with abrupt narrowing/cut off at the level of the second portion of the duodenum. The findings were suggestive of Lemmel syndrome, and to be confirmed by ERCP. DISCUSSION: This case illustrates the importance of maintaining a broad differential diagnosis and also brings awareness to a rare potential etiology of jaundice. The patient's excessive alcohol intake made acute alcoholic hepatitis the most likely initial suspected etiology of the patient’s jaundice. However, the continued elevation of transaminases and hyperbilirubinemia necessitated additional investigative studies. Imaging suggested the rare disorder known as Lemmel syndrome. Lemmel syndrome is caused by a periampullary duodenal diverticulum compressing the intra-pancreatic part of the common bile duct. This disorder should be considered in patients presenting with obstructive jaundice without malignancy or choledocholithiasis. Delayed identification can lead to unnecessary diagnostic testing, recurring symptoms, frequent hospital visits, and an increase in morbidity and mortality.Figure 1.: MRCP Findings.