Case 265: Lemmel Syndrome or Biliary Obstruction Due to a Periampullary Duodenal Diverticulum

History A 70-year-old man presented to the emergency department with fever, chills, rigors, and upper abdominal discomfort. Physical examination revealed jaundice and mild right upper quadrant tenderness. Laboratory tests revealed an increased C-reactive protein level of 133 mg/L (normal range, 0.2-0.9 mg/L), a white blood cell count of 11.69 ×10 9 /L (normal range, 4-10 ×10 9 /L), and an obstructive pattern on liver function tests, with a total bilirubin level of 3.5 mg/dL (59.9 µmol/L) (normal range, 0.4-1.9 mg/dL [6.8-32.5 µmol/L]), an alkaline phosphatase level of 716 U/L (11.9 µkat/L) (normal range, 39-99 U/L [0.65-1.65 µkat/L]), and an aspartate aminotransferase level of 88 U/L (1.47 µkat/L) (normal range, 12-42 U/L [0.20-0.70 µkat/L]). Serum amylase level was within normal limits at 84 U/L (1.40 µkat/L) (normal range, 38-149 U/L [0.63-2.48 µkat/L]). A clinical diagnosis of hepatobiliary sepsis due to ascending cholangitis was made. Relevant medical history included gastric carcinoma treated with a Billroth II surgical procedure 17 years earlier that was performed in conjunction with cholecystectomy. In addition, there were episodes of ascending cholangitis 6-12 months prior to the current admission that were managed conservatively with antibiotics at another institution. Blood cultures were positive for Klebsiella oxytoca . Administration of intravenous antibiotics was started, and CT examination of the abdomen was performed. Because a previous Billroth II procedure had been performed, the patient underwent percutaneous transhepatic cholangiography.