Dong Joo Seo, MD, Leandro R. Ramirez, MD, MHA, Amer Malik, MD; Roger Williams Medical Center, Providence, RI
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. Therapeutic options involve endoscopic extraction of entrapped material, endoscopic sphincterotomy, extracorporeal shock wave lithotripsy, diverticulectomy or biliodigestive anastomosis. This case introduces a rendezvous (RV) procedure as a treatment modality for Lemmel Syndrome.
Methods: A 64-year-old patient presented to the emergency department (ED) with abdominal pain and vomiting after eating fried chicken on the same day. She was hemodynamically stable except for a fever of 101 °F. She had leukocytosis, elevated LFTs, lipase, CRP. CT and MRI of abdomen showed acute pancreatitis, cholelithiasis, common bile duct (CBD) dilatation (2cm) and a distal transverse duodenal peri-ampullary diverticulum with mass effect, wall thickening with a 5 cm debris collection. Broad spectrum antibiotics and IV fluids were given. During the ERCP, a large amount of food residue was seen in the diverticulum withulceration rimming in its entrance of duodenum. This was removed with water jet. However, the CBD could not be cannulated due to severe inflammation, edema and inability to locate the ampullary entrance. A cholecystostomy tube was then placed by the interventional radiology (IR) team. Then, stent placement was achieved with a combined endoscopic-percutaneous transhepatic cholangiographic RV procedure with collaboration between gastroenterology team and IR teams. Discussion: Endoscopic intervention with sphincterotomy and stent placement is utilized in most cases of Lemmel syndrome. Due to the mass effect and the inflammation around PAD, direct visualization of ampulla and cannulation of bile duct during ERCP can be challenging. In our case, we were able to perform RV technique as an alternative option for the achievement of biliary access by crossing an anterograde-introduced wire percutaneously. In one study, CBD clearance rate in the RV group was 100%, as compared with ERCP group (89%). The mean duration of endoscopic procedure was significantly shorter by 9 minutes approximately. Hospital stay on between RV group and ERCP group was 4.3 days versus 8 days.
Axonal view of CT scan of abdomen showing debris filling duodenal diverticulum near ampulla measuring 2.8cm x 2.3cm x 3.3cm
Coronal view showing the debris
Disclosures: Dong Joo Seo indicated no relevant financial relationships. Leandro Ramirez indicated no relevant financial relationships. Amer Malik indicated no relevant financial relationships.