VA Caribbean Healthcare System San Juan, PR, United States
Juan Rojas-Robledo, MD, Frances Rodriguez-Berrios, MD, José Martin-Ortiz, MD, FACG VA Caribbean Healthcare System, San Juan, Puerto Rico
Introduction: Abdominal pain is a frequent cause of recurrent visits to the emergency room which can take on a different approach when anatomical variants such as periampullary duodenal diverticula are present (PAD). PAD are extraluminal outpouchings of the duodenal mucosa, and are mostly asymptomatic and often overlooked. However, compression of the common bile duct by PAD can result in obstructive jaundice, known as Lemmel’s syndrome. This is a rare clinical entity present in 5% of cases and its incidence increases with age. We discuss a case of an elderly male diagnosed with obstructive jaundice secondary to Lemmel’s syndrome .
Case Description/Methods: Case of a 79-year-old male with end stage renal disease, diabetes mellitus type 2, hypertension, and hypothyroidism who presented with a 3-week history of pruritus, abdominal pain and acholic stools. Physical examination was remarkable for icteric sclera, distended yet benign abdomen, and dry skin with multiple scratch marks. Labs were within patient’s baseline except for hyperbilirubinemia (6.5 MG/DL), elevated alkaline phosphatase (965 U/L) and elevated GGT above 1000 U/L. Hepatitis profile, ANA, and anti-mitochondrial antibody were all negative. Abdominal CT scan showed evidence of large diverticulum at the proximal transverse duodenum. MRCP confirmed duodenal diverticulum and showed splaying of the common bile duct and pancreatic duct with mild extrahepatic biliary dilation. Endoscopic retrograde cholangiopancreatography identified a large bezoar found inside the PAD causing obstruction of the common bile duct. The bezoar was successfully fragmented and removed, relieving the obstruction. Patient clinically improved.
Discussion: This case illustrates the importance of considering uncommon medical conditions when common complains are encountered in the setting of anatomic variances. Choledocholithiasis and malignancy will be suspected in an elderly with obstructive jaundice. In the case of PAD, abdominal pain is of greater significance among elderly population in which complications such as Lemmel’s syndrome becomes more prevalent. Our case shows how positive outcomes can be achieved from proper history taking, thorough diagnostic work-up, and all-inclusive differential diagnosis
Disclosures: Juan Rojas-Robledo indicated no relevant financial relationships. Frances Rodriguez-Berrios indicated no relevant financial relationships. José Martin-Ortiz indicated no relevant financial relationships.
Juan Rojas-Robledo, MD, Frances Rodriguez-Berrios, MD, José Martin-Ortiz, MD, FACG. P0076 - A Bezoar Presentation of Obstructive Jaundice: Lemmel's Syndrome, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.