Elderly Patient with Lemmel Syndrome
CITATION
Tajima A, Kurata H (2014) Elderly Patient with Lemmel Syndrome. JSM Gastroenterol Hepatol 2(1): 1010.
CLINICAL IMAGE
92 year old female without dementia had abdominal pain. The symptom was attenuated with enema. Five days later, she was admitted to our hospital with icterus. She denied abdominal pain. The temperature was 36.7°C. Labs were as follows; WBC 4600/μl, CRP 3.8 mg/dl, T-Bil 5.20 mg/dl, AST 136 IU/L, ALT 205 IU/L, ALP 546 IU/L. MRCP (Figure 1)
Figure 1: MRCP demonstrated stenosis of distal common bile duct due to extra-compression of periampullary diverticulum (arrow).
and abdominal CT (Figure 2)
Figure 2: Abdominal CT did not demonstrate mass lesions around distal CBD and wall thickening of CBD. Periampullary duodenal diverticulum was visualized (arrow).
are shown. MRCP and abdominal CT demonstrated stenosis of distal common bile duct due to extra-compression of periampullary diverticulum. Lemmel syndrome is defined that periampullary duodenal diverticulum often compressed the distal common bile duct and prevented the secretion of the bile [1,2]. Sulbactam Sodium, Cefoperazone Sodium, 2g per day was administered for 5 days for attenuated acute cholangitis. T-Bil decreased to 3.95 mg/dl. We performed ERCP on 5th day of admission for further exploration. Since small CBD (common bile duct) stone, 5mm in diameter, was visualized during ERCP, ERBD (endoscopic retrograde biliary drainage) stent was inserted after EST (endoscopic sphincterotomy). 5 days later, CBD stone was extracted with EML (endoscopic mechanical lithotripsy) after removing ERBD stent. T-Bil further decreased to 1.8 mg/dl, when the patient was discharged. In this case, distal cholangiocarcinoma could be one of the differential diagnosis [3]. However, we did not recognize mass lesions around distal CBD and wall thickening of CBD in CT. The flow of contrast media during ERCP through distal stenotic CBD was not disturbed. Indication of endoscopic diagnosis and therapy in elderly patients is difficult. In this patient, ERCP with EST and EML was definitely mandatory procedure.