S2029 Lemmel's Syndrome: A Rare Cause of Biliary Obstruction From a Common Entity
Bibliographic record
Abstract
Introduction: Lemmel’s syndrome is a rare cause of biliary obstruction due to duodenal periampullary diverticula (PAD). The presence of PAD is common, occurring in up to 30% of patients over age 70, thus clinical vigilance is required to obtain timely diagnosis. Case Description/Methods: An 82-year-old female was referred for incidental, asymptomatic cholestatic liver enzyme (LE) elevations. Blood work from 7 months prior was normal. She had a history of diabetes, dyslipidemia, and gout and she has been on atorvastatin and colchicine for years. She did not consume any alcohol or herbal medications. Her bilirubin was 4 umol/L, ALP 437 U/L, GGT 932 U/L, ALT 121 U/L, AST 67 U/L. Liver synthetic function was normal. She had a detailed initial workup: viral serologies showed resolved hepatitis B infection; autoimmune, genetic and metabolic workup were all negative. Abdominal ultrasound was normal, with no stones or biliary dilatation. Prior chart review showed she underwent a non-contrast computed tomography (CT) scan 7 months prior for acute onset of nausea, vomiting and diarrhea, which subsequently self-resolved. Her LEs were normal at that time. The CT scan did not show any biliary ductal dilation or cholelithiasis, but incidentally noted PAD. Magnetic resonance cholangiopancreatography (MRCP) was then ordered and this re-demonstrated the PAD, now compressing the distal common bile duct (CBD) with resultant upstream dilation. No stones, biliary strictures or masses were seen. A diagnosis of Lemmel’s syndrome was then made. As she was asymptomatic and this was her first presentation, she was managed conservatively. Her LEs normalized within 5 months. Endoscopic evaluation and possible sphincterotomy were recommended if she develops recurrent or chronic biliary obstruction. Discussion: This case highlights the diagnostic challenges in Lemmel’s syndrome and the value of past imaging review. Ultrasound is often the initial imaging of choice in LE elevation but has poor sensitivity for PAD and distal CBD dilation. Lemmel’s syndrome may also cause transient or recurrent biliary obstruction, thus timely and sensitive imaging is needed to capture the PAD as the culprit. In cases of unexplained acute cholestatic LE elevation, especially in the elderly population, prior imaging should be reviewed for PAD and urgent CT or MRCP should be considered as the initial investigation rather than abdominal ultrasound.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.002 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.002 | 0.001 |
| Insufficient payload (model declined to judge) | 0.005 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".