Essay Sample on Lemmel Syndrome: Rare Cause of Obstructive Jaundice

Introduction

According to Mora-Guzman and Martin-Perez (2019), the Lemmel Syndrome is a rare cause of obstructive jaundice due to the biliary mechanical compression by the juxtapapillary diverticulum and it is an extremely rare condition. Lemmel's syndrome causes the obstructive jaundice in the absence of gallstones nd the periampuliary tumors and it is associated with abdominal pains and in some cases acute cholangitis by mimicking the periambullary tumors which is more recurrent (Yoo, Kim, Huh, Lee, Jeon, Ha... & Kim, 2009). Most patients with the Lemmel's syndrome are diagnosed with jaundice and the CT scan, magnetic resonance and endoscopic ultrasonography are the most appropriate approaches of diagnosing patients with obstructive jaundice by being able to show in real time the disorder (Khan & Sharma, 2017). Therefore, the unusual representation of the obstructive jaundice is often due to the impacted intra-diverticular enterolith. Lemmel's syndrome diagnosis is very difficult and it is important to create awareness of the lemmel's syndrome possibility in patients with periampullary diverticula which is instrumental in promoting early diagnosis and management of the patient a factor which is instrumental for the overall patient recovery (Khan & Sharma, 2017). This paper will assess a patient case for Lemmel's syndrome to establish the differential diagnosis, case presentation of the patient, the disease pathophysiology, potential treatment and patient management, etiology of Lemmel's syndrome, prevalence, complications and the prognosis of the disease by referring on a single patient case.

Is your time best spent reading someone else’s essay? Get a 100% original essay FROM A CERTIFIED WRITER!

Save 25%

Case Presentation

The case study presents a 64 year old patient who comes to the emergency department with severe abdominal pains. The patient has experienced previous 3 episodes of abdominal pain accompanied by nausea, and vomiting after taking meals. The patient's abdominal pain began 1 week before she came to the emergency room in her mid-chest which she self-diagnosed as an increase in gas and took gas medication which temporarily eased her pain. However, her problems began a days ago when she experienced an episode of epigastric pain which occurred after she had took a meal. However, this time the abdominal pains are accompanied by overall weakness and vomiting of which she took the gas medication and she was relieved. However, she again experienced epigastric pain attack during the day of presentation but this time it was more severe. This incidence occurred after she had eaten a meal of fried chicken. The pain was located in the epigastric region and the upper quadrant pain which was accompanied by nausea, vomiting, chills and weakness. However, this time the patient does not experience any chest pain, palpitations, loss of consciousness, hematemesis, or GI bleed.

The patient does not use any alcohol and she did not have previous similar episodes or any abdominal surgery. The patient upon undergoing the Emergency Department course, cholecystostomy placement and ERCP was found to be hemodynamically stable, the abdominal ultrasound did show that the patient had a dilated common bile duct after which she was given Toradol 15 for pain management and Zofran for nausea. The patient was referred to have an MRI in the morning and admitted to GMF for acute pancreatitis etiology. In the GMF the patient had her electrolyte replenished and Dilaudid was administered for pain management. The treatment helped to push down her lipase to 5820 from a previous 7506. The liver function kept on deteriorating and after the MRI was conducted the results pointed out 4.5 cm debris and fluid-filled duodenal diverticulum near the ampulla after which an ERCP was conducted to assess the patient pancreatic and bile duct. During the procedure the patient developed a fever of 102.5 and blood pressure rose to 90s. The prolonged abdominal pains led to the repetition of a CT scan which indicated that the patient acute pancreatitis was worsening based on the peripancreatic inflammatory reaction in the absence of pancreatic necrosis. During discharge the patient was diagnosed with acute pancreatitis, duodenal diverticulum, hypokalemia, and hyponatremia.

Differential Diagnosis

Support for Conditions Considered

The primary diagnosis for the patient was ascending cholangitis, acute pancreatitis, duodenal diverticulum, hypokalemia, hyponatremia and choledocholithiasis. Of the diagnosis the most likely diagnosis was acute pancreatitis, ascending cholangitis, and the duodenal diverticulum. From the MRI, the CT scan and the symptoms there is enough evidence to show that the patient was suffering acute pancreatitis which was presented by the patient symptoms of abdominal pain, abdominal pain that occur after eating, fever, vomiting, nausea and a rapid pulse. The ascending cholangitis symptoms identifiable in the patient include; pain, fever, nausea, vomiting, low blood pressure, and dark urine. The choledocholithiasis symptoms identifiable with the patient include pain of the abdomen, jaundice, fever, and nausea. Duodenal diverticulum infection is another important diagnosis due to the inflamed duodenum. Lastly, hypokalemia and hyponatremia were the most unlikely diagnosis due to the patient presenting symptoms (Ono, Kamisawa, Tu, & Egawa, 2005). Although the patient experienced weakness, nausea, and vomiting there are other symptoms such as the low blood pressure and pain which the patient was experiencing.

Additional Investigations

There is need for more investigations on the patient to rule out the potential of Lemmel Syndrome which usually occurs concurrently with acute pancreatitis, bile duct stones, or ascending cholangitis which are all included in the patient differential diagnosis. The inflamation of the duodenal diverticum is one of the main supporting symptom for further investigation to rule out Lemmel Syndrome (Ono et al., 2005). The endoscope during the ERCP procedure found out that the diverticulum has been impacted by a large amount of food residue. Lemmel Syndrome is usually caused by mechanical obstruction of the common bile duct. The duodenal diverticular is adjacent to the ampulla which supports the need for additional investigation because the patient during the MRCP procedure there was 4.5 cm of debris and fluid near the ampulla which rules the possibility of Lummel Syndrome. The common bile duct of the patient also shows 1.9cm dilation without intrahepatic biliary ductal dilation. There is a direct correlation between periampullary duodenal diverticulum and gallstone disease which shows that the patients is highly likely having Lemmel Syndrome (Ono et al., 2005). The lateral compression of the patient distal common bile duct in the MCRP procedure without secretin injection is a depiction of periampullary duodenal diverticulum.

Treatment/Patient Management

The therapeutic treatment available for Lemmel Syndrome is through surgical resection, conservative treatment or endoscopic intervention. The most simplistic approach of treating the condition is through endoscopic sphineterotomy which helps to release the obstruction in the common bile duct (Desai, Wermers, & Beteselassie, 2017). The is consensus that the treatment of asymptomatic diverticulum using elective surgery is not justified. It is difficult to conduct surgical procedures for the diverticula area near the duodenum because for it to succeed there is need for the mobilization of the duodenum which is associated with retroperitoneal. Therefore, only symptomatic diverticulum should warrant for surgical or endoscopic interventions. Therefore, the treatment for the patient will highly depend on the comorbidity and the patient's quality of life (Prasetyaningtyas, Rahman, Sudoyo, & Fauzi, 2015).

Conclusion

Lemmel Syndrome is a benign disease which is common in the elderly and it is usually diagnosed through MRCP imaging procedure to establish the disease correctly which is instrumental in preventing patient mismanagement like in the case of the patient who is misdiagnosed. Surgical excision of the diverticulum is appropriate in the clinical cases. The excision of the diverticulum is difficult as a treatment method and increases potential mortality.

References

Desai, K., Wermers, J. D., & Beteselassie, N. (2017). Lemmel syndrome secondary to duodenal diverticulitis: a case report. Cureus, 9(3). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5376190/

Khan, B. A., Khan, S. H., & Sharma, A. (2017). Lemmel's syndrome: a rare cause of obstructive jaundice secondary to periampullary diverticulum. European journal of case reports in internal medicine, 4(6). Retrieved from https://journals.lww.com/ajg/Fulltext/2016/10001/Lemmel_s_Syndrome__A_Rare_Cause_of_Obstructive.1165.aspx

Mora-Guzman, I., & Martin-Perez, E. (2019). Lemmel's syndrome. Gastroenterologia y hepatologia, 42(2), 113-114.

Ono, M., Kamisawa, T., Tu, Y., & Egawa, N. (2005). MRCP and ERCP in Lemmel syndrome. Jop, 6(3), 277-278. Retrieved from https://www.researchgate.net/profile/Naoto_Egawa/publication/7858584_MRCP_and_ERCP_in_Lemmel_syndrome/links/0f31753c5b16d73789000000.pdf

Prasetyaningtyas, A., Rahman, P. A., Sudoyo, A. W., & Fauzi, A. (2015). Treatment Options of Lemmel's Syndrome: A Case of Benign Obstructive Jaundice in The Elderly. The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy, 16(2), 120-125. Retrieved from http://www.ina-jghe.com/journal/index.php/jghe/article/view/491

Yoo, K. S., Kim, S. J., Huh, K. R., Lee, K. H., Jeon, G., Ha, J. W., ... & Kim, J. H. (2009). Endoscopic papillary large balloon dilation with minor endoscopic sphincterotomy in the management of difficult bile duct stones. Gastrointestinal Endoscopy, 69(5), AB154. Retrieved from http://www.ina-jghe.com/journal/index.php/jghe/article/view/491