Silent Culprit: Duodenal Diverticulum Sparks Jaundice
A case report by Masome Aghaei Lasboo, MD, at the Department of Internal Medicine, Guilan University of Medical Sciences, Rasht, Iran, and colleagues, highlighted the diagnostic challenges of Lemmel syndrome, a condition frequently misdiagnosed due to its rarity and non-specific presentation.
The Patient and His History
The patient was admitted to the hospital with no significant medical history after experiencing ten days of intermittent fever, nausea, and vomiting two to three times daily, particularly after meals, along with general jaundice and abdominal pain.
Jaundice was first noted in the eyes and progressed to involve the face and body by day 5.
Four days prior to hospitalisation, the patient experienced colicky abdominal pain in the epigastric and right upper quadrant regions. Each episode lasted for 20-30 minutes.
Importantly, the pain did not worsen with eating, bowel movements, or changes in body position, suggesting a non-intestinal aetiology. He also reported significant weight loss over the past 6 months. Additional symptoms included nocturnal sweats, fatigue, generalised weakness, and anorexia. His medication, family, social, travel, and allergy histories were unremarkable.
Findings and Diagnosis
On admission, the vital signs were pulse 85 beats/min, temperature 37.0 °C, respiratory rate 18 breaths/min, blood pressure 90/60 mm Hg, and oxygen saturation 95% on room air.
Abdominal examination revealed no palpable masses or areas of tenderness. Murphy's sign was negative. The liver span was approximately 10 cm. The patient had no history of gall bladder disease or alcohol use.
Laboratory results were as follows:
White blood cell count: 28,900 cells/μL
Platelet count: 60,000/μL
Haemoglobin: 9 g/dL
Alanine aminotransferase: 61 U/L
Aspartate aminotransferase: 89 U/L
Alkaline phosphatase: 430 U/L
Total bilirubin: 23.4 mg/dL
Direct bilirubin: 12.1 mg/dL
Serological tests for hepatitis C virus antibodies, hepatitis B surface antigen, and anti-leptospira antibodies were negative.
An initial ultrasound of the bile ducts and liver showed that the CBD was nearly normal in diameter (5-7.6 mm), with no evidence of stones. The gall bladder had an average wall thickness and contained small amounts of sludge, but no stones were visualised. Follow-up imaging with CT and MRI revealed dilation of the middle and proximal segments of the CBD, measuring 11-12 mm in diameter. A 21-25 mm PAD was noted on the medial wall of the second part of the duodenum, compressing the distal CBD and leading to upstream bile duct dilation. The presence of gas and food particles within the diverticulum indicated mechanical obstruction.
Upper gastrointestinal endoscopy was performed to further evaluate the patient. It revealed gastroesophageal reflux disease, Los Angeles class B, mild antral gastritis, and bile reflux.
The second part of the duodenum showed normal mucosa without ulcerations or masses. These findings ruled out obstructive tumours or intrinsic duodenal lesions and supported the diagnosis of Lemmel syndrome, caused by extrinsic compression from the PAD. The patient was treated with intravenous fluids, ceftriaxone, and metronidazole during hospitalisation. After his pain, fever, and laboratory markers normalised, he was discharged after 23 days.
Discussion
'Although Lemmel syndrome is rare, it remains an important differential diagnosis for obstructive jaundice, especially in the absence of gallstones or tumours. Early recognition and imaging-based diagnosis are critical to prevent complications such as cholangitis and pancreatitis,' the authors wrote.
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