A biliary dilemma resolved by endoscopy: Lemmel syndrome as a cause of non-lithiasic acute obstructive cholangitis

Abstract

Acute cholangitis is commonly caused by choledocholithiasis. A diagnostic and surgical dilemma arises when no stones are found. Lemmel syndrome—biliary obstruction secondary to a periampullary duodenal diverticulum—is a rare but crucial etiology to consider. This report describes its presentation, diagnosis, and endoscopic management. We present the case of a 73-year-old female with severe acute obstructive cholangitis without evidence of lithiasis. Evaluation included clinical history, physical examination, laboratory tests, ultrasound, and magnetic resonance cholangiopancreatography. The definitive diagnosis was established via endoscopic retrograde cholangiopancreatography (ERCP). Clinical and biochemical findings were consistent with cholangitis, but imaging studies revealed no choledocholithiasis. ERCP demonstrated a 30 mm periampullary duodenal diverticulum containing the major papilla, which was covered with food residue, confirming Lemmel syndrome. Management involved diverticular cleansing and endoscopic sphincterotomy, which successfully resolved the obstruction. This case highlights the importance of including Lemmel syndrome in the differential diagnosis of non-lithiasic acute cholangitis. Detailed endoscopic evaluation is essential to identify this anatomical alteration and avoid unnecessary surgical interventions. Targeted endoscopic treatment represents an effective and minimally invasive strategy.