Periampullary Duodenal Diverticulum Research Articles

Lemmel Syndrome - Early Diagnosis of Rare Disease Presenting with Commonest Symptom

One of the most frequent causes of visits to the emergency room is abdominal pain and approximately 10-12% of cases occur globally. [1] From generalized mild pain to major life-threatening disorders, there are a number of considerations to be identified. The causes of pain with signs of biliary obstruction range from most common diagnosis of choledocholithiasis to complex worrisome diagnosis of carcinoma.[2] Up to 27% of individuals undergoing upper gastrointestinal tract assessment have duodenal diverticula, with periampullary diverticula (PAD) being the most prevalent kind. Periampullary diverticula (PAD) are extraluminal duodenal mucosal outpouchings that often form in the medial side of the second and third parts of the duodenum within a radius of 2 to 3 cm from the ampulla of vater.[3,4] Periampullary duodenal diverticulum (PAD) in the absence of choledocholithiasis or neoplasm causing biliary obstruction is diagnosed as Lemmel syndome.[5]

Pancreatic panniculitis associated with periampullary duodenal diverticulum

Introduction. Pancreatic panniculitis (PP) is a rare type of lobular panniculitis that manifests as painful erythematous nodules on the skin of the lower extremities. Subcutaneous fat necrosis caused by the release of pancreatic enzymes is the underlying cause of the disease, affecting around 2?3% of patients with pancreatic diseases. Case report. We present a case of a 58-year-old male patient who was admitted to our clinic due to the appearance of painful erythematous nodules on the lower extremities and trunk. Laboratory results revealed increased levels of pancreatic enzymes, amylase, and lipase, as well as heightened levels of glucose and inflammation markers. The histological analysis of the skin lesion biopsy revealed the presence of predominantly lobular panniculitis in the hypodermis, with areas of fatty tissue necrosis/saponification and remnants of adipocytes (?ghost cells?). Abdominal computed tomography scan demonstrated peri-ampullary diverticulum (PD) of the duodenum, with no signs of pancreatitis or other pancreatic abnormalities. Esophagogastroduodenoscopy showed a wide opening of PD in the D2 segment of the duodenum. The patient was successfully treated with pancreatin therapy, resulting in a significant reduction of skin lesions and decreased levels of pancreatic enzymes. Conclusion. Duodenal PDs can be the cause of PP, most likely due to the pressure they exert on the pancreatic duct, which can lead to elevated values of pancreatic enzymes. Depending on the individual characteristics of the patient, symptomatic duodenal PD may be treated with operative or non-operative measures. Treatment of PP primarily involves addressing any underlying medical condition.

Lemmel Syndrome as Rare Cause of Secondary Sclerosing Cholangitis: An Unusual Presentation and Literature Review

Lemmel’s syndrome is a rare and misdiagnosed cause of obstructive jaundice, It corresponds to cholestatic disease secondary to compression of the main bile duct by a periampullary duodenal diverticulum with secondary dilation of the extra- and intra-hepatic bile ducts. Approximately 5% of duodenal diverticles can cause symptoms and 1% have complications, with colangitis being the most common. Lemmel syndrome is a type of intermittent obstructive jaundice without the presence of coledocolithiasis. Late diagnosis of this entity is common and may lead to unnecessary further investigations and therapeutic delay. There are no cases reports published associated with secondary sclerosing colangitis.

Bezoar in a periampullary duodenal diverticulum causing pancreaticobiliary obstruction and ascending cholangitis

Ascending cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain. It is caused by stasis and infection in the biliary tract with severity ranging from mild to life threatening. The most frequent causes of biliary obstruction and ascending cholangitis are choledocholithiasis, benign biliary stricture, and obstructing malignancy. In this report, we describe a rare case of a large periampullary duodenal diverticulum impacted with a food bezoar, causing pancreaticobiliary obstruction and ascending cholangitis.

Lemmel syndrome: a rare cause of obstructive jaundice (case report)

Obstructive jaundice through periampullary duodenal diverticulum (PAD), without gallstones or neoplasms, was first described by Lemmel in 1934 as Lemmel syndrome. PAD can be diagnosed incidentally or suspected in patients with obstructive jaundice and nonspecific abdominal pain. It is a rare and benign condition that can be misdiagnosed as malignancy. Ignoring this, can cause morbidity and mortality. Definite diagnosis is made by Endoscopic Retrograde Cholangiopancreatography (ERCP). An accurate diagnosis is very important to ensure patient management and to avoid complications of delayed care. We present a case who coincidentally was diagnosed with PAD and thus obstructive jaundice.

S1852 When Life Gives You Lemmel's, Call Your Gastroenterologist

Introduction: Lemmel’s syndrome is defined as obstructive jaundice caused by periampullary duodenal diverticulum (PAD), leading to bile duct compression and dilation. PAD leading to the obstruction of the ampulla of Vater is the most common, with an incidence as high as 27%. Most PAD are found incidentally and are suspected to be found in up to 22% of the population, however, some patients can have life-threatening pathology, necessitating quick intervention. This case outlines a patient with this rare pathology and discusses when to choose specific therapeutic options. Case Description/Methods: A 77-year-old Caucasian female with a history of cholecystectomy 20 years ago presented to the emergency department with a 1-day history of epigastric abdominal pain, mild fever, jaundice, and non-bloody diarrhea. Laboratory evaluation was notable for a lipase of 3326 U/L and transaminitis with ALP 908 IU/L, AST 234 U/L, ALT 153 U/L, and total bilirubin 7.2 mg/dL. CT abdomen with IV contrast revealed moderate-severe pancreatitis and intra/extrahepatic biliary ductal dilation up to 19 mm in diameter with additional dilation of the pancreatic duct. A subsequent MRCP revealed a large periampullary duodenal diverticulum with obstruction of the common bile duct, consistent with Lemmel’s syndrome, and possible duodenal diverticulitis (Figure A, B). Piperacillin-tazobactam was initiated due to concern for ascending cholangitis and diverticulitis. ERCP was performed the following morning, which revealed a large duodenal diverticulum in the second portion of the duodenum with fecalized material impacted within the diverticulum (Figure C). The entire biliary ampulla was obscured by obstructing material and surrounding ulceration was noted. Several attempts to remove the impaction were unsuccessful. A temporary PTC drain was placed with interval improvement in her pain and lab abnormalities. The patient was transferred to another facility for advanced endoscopy, where she had successful removal of obstruction and intra/extrahepatic stenting. Discussion: Therapeutic options vary, but ERCP is considered the initial treatment of choice because it allows for the placement of a biliary stent and a sphincterotomy. If Lemmel’s is due to chronic papillary fibrosis or sphincter of Oddi dysfunction, then an endoscopic sphincterotomy is the preferred therapy. If the disease is severe or complicated, a diverticulectomy is recommended in patients who are at lower risk for adverse complications.Figure 1.: A) Coronal slice from MRI abdomen and pelvis demonstrating a large periampullary duodenal diverticulum with obstruction of the common bile duct. B) Transverse slice from MRI abdomen and pelvis demonstrating a large periampullary duodenal diverticulum with obstruction of the common bile duct. C) Image obtained during ERCP revealing impacted fecalized material within a large duodenal diverticulum in the second portion of the duodenum with surrounding ulceration.

S1843 The Path of Least Resistance: A Case of the Lemmel

Introduction: Lemmel Syndrome is defined as obstructive jaundice caused by a periampullary duodenal diverticulum (PAD) compressing the intrapancreatic common bile duct (CBD) with resultant bile duct dilatation and obstruction. Management is based on symptomatology, ranging from conservative management to endoscopic extraction of retained food debris, or surgery. We present a unique case of Lemmel Syndrome in a patient who suffered from recurrent obstructive jaundice and underwent multiple endoscopic and ultimately, surgical interventions Case Description/Methods: A 56-year-old obese female with a history of alcohol use disorder initially presented with right upper quadrant abdominal pain for 2 days. Physical exam was remarkable for right upper quadrant tenderness. Labs revealed total bilirubin 3 mg/dL. Complete blood count was within normal limits. Viral hepatitis panel and CA 19-9 were unremarkable. Ultrasound gallbladder showed cholelithiasis without cholecystitis with mild CBD dilatation. MRCP revealed a large 6 cm multiloculated mass centered near the pancreatic head/ampulla of Vater, with internal heterogeneity and multiple air-fluid levels and internally contiguous with duodenal lumen. She was given broad spectrum antibiotics and an upper endoscopy with endoscopic ultrasound was performed revealing a large, non-bleeding periampullary diverticulum impacted with food debris. The food debris was extracted. Multiple such procedures were needed in a short period of time. She continued to suffer from recurrent obstructive jaundice for several months, requiring a cholecystectomy, Roux-En Y hepaticojejunostomy, and gastric antrum resection with Roux-En Y BillRoth II gastrojejunostomy in an attempt to divert food debris away from the diverticulum. She has now developed stenosis at the hepaticojejunostomy requiring ERCP with dilation of the anastomosis, and stenting, as well as percutaneous transhepatic cholangiography, internal external biliary drain placement, lithotripsy of hepatic duct stones, and covered metal stent placement. (Figure) Discussion: Treatment of Lemmel Syndrome incorporates a variety of modalities. A conservative approach is usually preferred, but invasive intervention may sometimes be required. The most definitive approach would be a Whipple procedure. However, in an obese patient, this would be associated with significant morbidity and mortality risk. Our case portrays an unusual approach which offered the patient a less invasive combined endoscopic, interventional radiology and surgical treatmentFigure 1.: A: Initial MRI which shows duodenal diverticulum with biliary dilation consistent with Lemmel Syndrome B: Initial Cholangiogram: Stent within left hepatic duct as well as central right hepatic duct appearing goblet shaped with stones (as shown with arrows) C: Subsequent imaging reveals right hepatic duct status post stone extraction, appearing relatively normal (compare with Image B).

S3439 Lemmel Syndrome Due to Periampullary Diverticular Food Impaction

Introduction: Lemmel Syndrome is a rare cause of mechanical biliary obstruction attributed to periampullary duodenal diverticula (PAD). It was first described in 1934 as obstructive jaundice in the absence of biliary stones or malignancy. The majority of PAD are asymptomatic, however, about 5% have symptomatic disease. We present a symptomatic case. Case Description/Methods: An 80-year-old woman with history of cholecystectomy, coronary artery disease, hypertension, and diabetes was transferred from a free-standing emergency room for acute pancreatitis. She had a one day history of postprandial epigastric pain with radiation to the back. Labs on presentation included lipase above 4000 U/L, BUN 27 mg/dL, AST 316 U/L, ALT 422 U/L, ALP 292 IU/L, total bilirubin 0.6 mg/dL. Abdominal ultrasound revealed 12mm common bile duct (CBD) with intrahepatic ductal dilatation. MRCP showed intra and extrahepatic biliary ductal dilatation with dilated pancreatic duct and a 3.6 cm fluid filled periampullary diverticulum. ERCP showed a large periampullary duodenal diverticulum with food impaction causing obstruction of the ampullary orifice which was removed with forceps. Cholangiogram revealed dilation of pancreatic, common bile, and intrahepatic ducts without any filling defects. Patient improved and was discharged home. (Figure) Discussion: The incidence of duodenal diverticula is approximately 17% with PAD being the most common type. PADs are pseudo-diverticula most commonly found in the second part of the duodenum and they pose a cannulation challenge during ERCP with an increased risk of complications. PAD in the setting of biliary obstruction is known as Lemmel Syndrome. It can cause biliary obstruction by sphincter of Oddi dysfunction, direct obstruction, or via external compression by fluid or material-filled PAD. In our case, there was biliary compression due to a food-filled PAD. Cross sectional imaging is critical for diagnosis, however, ERCP is the gold standard. Several therapeutic modalities including endoscopic extraction of entrapped food or stones, extracorporeal shock wave lithotripsy, and laparoscopic diverticulectomy have been used. Our case required endoscopic extraction of diverticular food debris and adds to the limited published cases to date. Lemmel Syndrome requires a high index of suspicion when a PAD is found in the setting of biliary obstruction.Figure 1.: A. MRCP image showing a large periampullary diverticulum packed with debris. B. ERCP image of food impacted inside periampullary diverticulum. C. MRCP image demonstrating a dilated common bile duct in absence of choledocholithiasis.

Síndrome de Lemmel: una causa infrecuente de colangitis aguda

Lemmel syndrome is a rare entity that causes biliary obstruction due to compression of the common bile duct by a periampullary diverticulum. It can manifest as acute cholangitis and is often underdiagnosed. However, once identified, it can be successfully treated with endoscopic retrograde cholangiopancreatography, being one of the most used methods. Lemmel syndrome should be considered in elderly patients with a diagnosis of periampullary duodenal diverticulum, once the presence of choledocholithiasis and pancreatobiliary neoplasms have been ruled out.

LEMMEL SYNDROME – RARE CAUSE OF CHOLANGITIS : A CASE REPORT

Introduction: Lemmel Syndrome is a rare cause of the biliary mechanical compression by the juxtapapillary pseudo-diverticulum, in the absence of gallstones or periampullary tumors. Most periampullary diverticula are asymptomatic. However, complications may occur in about 5%, including diverticulitis, pancreatitis, cholangitis, choledocholithiasis, enterolith, bezoar formation, intestinal obstruction, bleeding and perforation. Case report: A 60-year-old woman presented with abdominal pain,fever and jaundice of acute onset. She was hemodynamically stable except for a fever of 101 °F. Initial blood work revealed a WBC 14,500/mm3, ALT 118 IU/L, AST 189 IU/L, ALP 356 IU/L, T bilirubin 7.2 mg/dl. CT and MRI of abdomen revealed periampullary diverticulum compressing distal common bile duct causing proximal dilatation consistent with Lemmel syndrome. Patient was managed with broad spectrum antibiotics and other supportive measures in view of cholangitis. Patient underwent ERCP with CBD stenting. Patient’s lab parameters improved steadily and was asymptomatic in few days. Discussion: Our patient had abdominal pain associated with leukocytosis and cholangitis due to extrinsic compression of the distal CBD. Lemmel syndrome can be transient in nature as a result of a periampullary duodenal diverticulum causing extrinsic compression of the CBD. This can sometimes progress to cholangitis, as seen in our patient. Early diagnosis is necessary to avoid extensive and invasive workup. Management is often supportive, although in some cases with recurrent infection or persistent biliary obstruction, surgical diverticulectomy can be considered. Conclusion: Lemmel syndrome should be kept as a rare differential when evaluating patients with biliary obstruction.

S2498 Lemmel Syndrome: An Unusual Presentation with Gastric Outlet Obstruction

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.

Lemmel's syndrome: an uncommon complication of periampullary duodenal diverticulum.

Lemmel's syndrome is an uncommon entity that causes obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledolithiasis or neoplasia. To date, there are few published cases and the etiopathogenesis remains unclear.

S1416 A Not so Simple Case of Obstructive Jaundice

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.

Duodenal diverticulum causing obstructive jaundice - Lemmel's syndrome.

The duodenum is the second most common location of intestinal diverticula. Periampullary duodenal diverticulum rarely causes obstructive jaundice and this condition was first described by German surgeon Gerhard Lemmel in 1934. Lemmel's syndrome is defined as obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledocholithiasis or a neoplasm.

1343 A Rare Case of Lemmel Syndrome

INTRODUCTION: Lemmel syndrome is a rare condition in which a periampullary duodenal diverticulum compresses the distal common bile duct (CBD) resulting in obstructive jaundice in the absence of choledocholithiasis or tumor. We present a rare case of Lemmel syndrome in an elderly patient below. CASE DESCRIPTION/METHODS: An 83-year-old woman with a past medical history of Crohn's disease and pancreatic cysts was transferred to our facility for management of biliary obstruction. She had noted a four-month history of progressive early satiety, post-prandial right upper quadrant abdominal pain, post-prandial emesis, poor oral intake, and significant weight loss. On presentation, labs were significant for WBC of 11.6 k/mm3, AST of 242 U/L, ALT of 1677 U/L, alkaline phosphatase of 1347 U/L, total bilirubin of 3.4 mg/dL, and lipase of 260 U/L. She underwent ERCP and was found to have a large periampullary diverticulum containing the major papilla. Cholangiogram revealed a tortuous bile duct and severe intra- and extrahepatic biliary dilation. A sphincterotomy was performed and multiple balloon sweeps were done with no stone extraction. A 10 F × 8 cm fully covered metal biliary stent (FCSEMS) was placed in the bile duct and she had improvement in her appetite, abdominal pain, and liver function tests. On follow up ERCP, the bile duct maintained a straightened position. DISCUSSION: Lemmel syndrome is characterized by obstructive jaundice caused by periampullary duodenal diverticulum (PAD) compressing the intra-pancreatic part of the CBD with resultant upstream dilatation of the extra- and intra-hepatic bile ducts. PAD is a pseudo-diverticula consisting of an extraluminal out-pouching of duodenal mucosa and lacks a muscularis layer. PAD develops within a 2-3 cm radius from the ampulla of Vater. Periampullary duodenal diverticuli are mostly asymptomatic and majority are diagnosed incidentally. When inflamed, they can cause pancreaticobiliary complications such as obstructive jaundice, cholangitis, pancreatitis, and stone formation. They are diagnosed on imaging such as CT scan, MRCP, and barium studies, which can show lateral compression of the distal CBD by the diverticulum. ERCP with sphincterotomy and biliary stent placement has shown to reduce the risk of morbidity and mortality, although diverticulectomy remains standard of care for PAD. Lemmel syndrome is rare but should be considered in the differential diagnosis for obstructive jaundice in patients with a periampullary duodenal diverticulum.

1314 Lemmel Syndrome in a Centenarian

INTRODUCTION: Obstructive jaundice can be caused by intraluminal forces (choledocholithiasis), extraluminal forces (carcinoma) or transmural forces (choledochal cysts). In addition to the above, a rare cause of obstructive jaundice includes periampullary diverticula - Lemmel's syndrome. This syndrome involves a periampullary duodenal diverticulum that can compress the common bile duct resulting in obstructive jaundice. These diverticula are extraluminal and their prevalence increases with age and given that the majority are asymptomatic, they can be overlooked in imaging studies. It is estimated that 5% of patients experience acute symptomatology due to these diverticula. CASE DESCRIPTION/METHODS: This is the case of an over 90-year-old male with medical history of hypertension and Alzheimer's dementia who came to the ER due to right upper quadrant abdominal pain the day prior to admission. Physical wasexam remarkable for epigastric and right upper quadrant tenderness. Labs with transaminitis (ALT:1294 U/L, AST: 1166 U/L), alkaline phosphatase 366 U/L, total bilirubin 3.2 mg/dL, amylase: 123 U/L, lipase: 98 U/L). Abd/pelvic CT scan reported prominence of the intrahepatic and extrahepatic biliary system. The common bile duct measuring 8-9 mm, proximal pancreatic duct dilated approximately 4 mm, and the common bile duct extending to a large duodenal diverticulum without evidence of choledocholithiasis. Considering the patients advanced age, he was treated with conservative medical management including antibiotic therapy. DISCUSSION: This case highlights the importance of taking a holistic approach to patient care especially patients of advanced age who may have findings suggestive of a diagnosis that is overlooked as it is uncommon. The literature states that the detection rate of duodenal diverticula ranges from 1% to 27%. In addition, the majority of peri-ampullar diverticula are asymptomatic however 5% of cases can present with bleeding, jaundice or intestinal obstruction. Misdiagnosis of this condition may lead to erroneous management and delay in treatment in patients who are able to receive aggressive management.

How to facilitate cannulation of an intradiverticular papilla: a technique with two devices in one channel using pediatric forceps.

The proportion of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with a periampullary duodenal diverticulum ranges in the literature from 9 % to 32 % [1]. The prevalence of periampullary diverticula increases with age, and they are associated with a higher risk of choledocholithiasis [2]. In a few series, they have been identified as a risk factor for difficulty in and failure of biliary catheterization [3]. Several techniques have been proposed to facilitate cannulation, such as clips, or in one case forceps [4] [5]. [Video 1] shows three patients who benefited from our technique involving double instrumentation in one channel for the treatment of biliary obstruction with peridiverticular papillae. Among 7151 ERCPs performed between 2008 and 2017, a duodenal diverticulum was found in 346 patients (5 %). Among these, nine patients with a non-visible or non-reachable orifice benefited from the previously described technique for cannulation. The objective was to reverse the papilla’s orifice to stabilize it in front of the sphincterotome. The procedures were performed with a duodenoscope (Olympus TJF 160; operating channel 4.2 mm). The devices used were a sphincterotome (Cotton Cannulatome II; Cook Medical, USA) loaded with a 0.035-inch guidewire (JagWire; Boston Scientific, USA) and pediatric biopsy forceps (Captura 1.8 mm; Cook Medical), which were simultaneously introduced into the operating channel. The papilla was grasped at its base and pulled back towards the tip of the sphincterotome, which was advanced to catheterize the bile duct with the wire ([Fig. 1]). The procedure was successful in less than 10 minutes without the need for a precut in all of the patients. The findings were biliary stones in six patients, undetermined stricture in two patients, and pancreatic cancer in one patient. No adverse events occurred. In conclusion, this approach using pediatric forceps simultaneously introduced with the sphincterotome to fix the papilla and facilitate cannulation is very useful, safe, and effective in patients with a periampullary diverticulum and difficult access to the orifice, helping to avoid the need for a challenging precut.

A duodenal diverticula causing a Lemmel syndrome: A case report

Introduction: Lemmel syndrome corresponds to cholestatic disease secondary to compression of the main bile duct by a periampullary duodenal diverticulum. Case Report: We report a new case of Lemmel syndrome, caused by a periampullary duodenal diverticulum compressing the bile ducts leading to cholestasis. Computed tomography and MRI allows diagnosis, eliminate pancreatic origin, and avoid heavy surgery. Conclusion: The duodenal diverticulum is a rare entity, remains asymptomatic for a long time, often discovered by the stage of complications, CT and MRI make it possible to make the diagnosis and to propose an adequate treatment.

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

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

ERCP Features and Outcome in Patients With Periampullary Duodenal Diverticulum

ERCP Features and Outcome in Patients With Periampullary Duodenal Diverticulum