Recurrent cholangitis caused by a giant duodenal diverticulum (Lemmel syndrome) – effective treatment with endoscopic sphincterotomy

A 70-year-old male was admitted with abdominal pain and jaundice. Past medical history was relevant for severe chronic obstructive pulmonary disease and multiple cardiovascular risk factors. Biological tests revealed leukocytosis (18.5 x 109/L), hyperbilirubinemia (total bilirubin of 4.9 mg/dL and direct bilirubin of 2.8 mg/dL) and elevated C reactive protein (13.64 mg/dL) and liver enzymes (alanine aminotransferase of 562 UI/L, aspartate aminotransferase of 689 UI/L and alkaline phosphatase of 378 U/L). Abdominal CT showed a dilated biliary tree and no obstructive lesions. The patient started on antibiotics due to suspected acute cholangitis. A magnetic resonance cholangiopancreatography was performed, showing a giant duodenal diverticulum (shown in Fig. 1) involving the distal segment of the common bile duct almost circumferentially, leading to its collapse and upstream dilatation of intra and extrahepatic bile ducts, without luminal stones or stenosis. Imaging findings were consistent with Lemmel syndrome (LS).