S2498 Lemmel Syndrome: An Unusual Presentation with Gastric Outlet Obstruction

Abstract

Introduction: Lemmel syndrome is a rare clinical entity characterized by a periampullary duodenal diverticulum causing compression and dilatation of the pancreatic and common bile ducts, classically accompanied by obstructive jaundice. Gastric outlet obstruction (GOO) is not a known complication of this syndrome, nor are there standardized approaches to its treatment. We present the first documented case of Lemmel syndrome presenting as GOO and its successful treatment with endoscopic diverticular lavage. Case Description/Methods: An 82-year-old woman presented with abdominal pain and non-bloody non-bilious emesis. On arrival, she was hemodynamically stable and anicteric. Computed tomography (CT) with contrast revealed a 2.7x3.7x5.2 cm complex pancreatic head mass containing air and debris, contiguous with the duodenum at the junction of the 2nd and 3rd segments with dilatation of the common bile (1 cm) and main pancreatic duct (0.6 cm), concerning for a pancreatic neoplasm. There was also GOO manifested as a markedly distended stomach with distal gastric and proximal duodenal wall thickening and hyperenhancement. Esophagogastroduodenoscopy (EGD) with endoscopic ultrasonography (EUS) showed no signs of significant abnormalities within the pancreas. However, a large non-bleeding periampullary diverticulum in the second portion of the duodenum containing a large amount of food debris was visualized and was found to be obstructing the common bile and main pancreatic ducts causing ductal dilatation. Endoscopic diverticular lavage with removal of food debris was performed. Her diet was quickly escalated, her symptoms resolved, and she was discharged the following afternoon. Repeat CT 11 days post-procedure showed resolution of GOO and reduced biliary ductal dilation and diverticular size. At 1-month follow-up, she remained asymptomatic and was tolerating high-fiber diet without clinical signs of gastric outlet or biliary obstruction. Discussion: Lemmel syndrome is a rare cause of GOO in the setting of pancreatic and common bile duct compression and dilatation with or without the presence of jaundice. Until now, there have been no reported cases of GOO secondary to Lemmel syndrome, nor its successful treatment with a simple diverticular lavage. It is important that physicians consider this diagnosis and treatment strategy in order to deliver cost-effective and appropriate care to patients presenting with GOO in the setting of a periampullary diverticulum with evidence of dilated biliary and pancreatic ducts.Figure 1.: CT abdomen pelvis demonstrating a 2.7 x 3.7 x 5.2 cm complex pancreatic head mass containing air and debris (A), contiguous with the duodenum at the junction of the second and third segments (B) with moderate 1.0 cm dilatation of the common bile duct (C) and 0.6 cm dilatation of the main pancreatic duct (D, E). CT abdomen pelvis demonstrating gastric outlet obstruction manifested as markedly distended stomach with distal gastric and proximal duodenal wall thickening and hyperenhancement (F).Figure 2.: Endoscopic ultrasonography (EUS) of the head (A), neck (B), and body (C) of the pancreas without signs of significant endosonographic abnormalities.Figure 3.: Large non-bleeding periampullary diverticulum in the second portion of the duodenum containing a large amount of food debris visualized and found to be obstructing the common bile and main pancreatic ducts causing ductal dilatation.Figure 4.: CT abdomen pelvis demonstrating improvement in common bile duct dilation (A) and diverticular size with resolution of radiographic evidence of gastric outlet obstruction (B, C) 10 days after endoscopic diverticular lavage. Bile duct measuring 0.7 cm, previously 1.0 cm. Diverticular dimensions measuring 1.9 x 3.6 x 3.7 cm (AP by transverse by craniocaudal), previously 2.7 x 3.7 x 5.2 cm. Pancreatic duct was poorly visualized, and comparison could not be made.