ABSTRACT
Lemmel syndrome, characterized by biliary and pancreatic duct obstruction secondary to a periampullary duodenal diverticulum (PAD), remains a rare and often overlooked diagnosis. Although duodenal diverticula are found in approximately 23% of the population, only about 5% of these cases lead to complications such as obstructions. A new case of Lemmel syndrome is demonstrated in the article about a middle-aged woman with chronic epigastric pain and right upper abdominal quadrant initially misdiagnosed as cholelithiasis. The accuracy of diagnosis was made possible by multimodal imaging methods, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) with oral contrast when a diffuse common bile duct was compressed by a PAD. Additionally, it highlights the necessity of including Lemmel syndrome in cases where patients have dilated bile ducts without calculi or mass lesions while emphasizing advanced imaging techniques for the revelation of structural malformations that underlay these conditions. The endoscopic intervention was minimally invasive but effective in relieving symptoms through sphincterotomy followed by laparoscopic cholecystectomy and biliary stent placement, thus making a point of the need for multiple disciplinary approaches toward treatment rare phenomenon like this one. This case report not only sheds light on the diagnostic and therapeutic avenues for Lemmel syndrome but also serves as a valuable educational resource for healthcare professionals. It emphasizes the need for heightened clinical vigilance and the adept use of imaging modalities in cases of biliary obstruction with obscure etiology. By contributing to the growing knowledge of this rare condition, we aim to facilitate timely diagnosis and optimize patient outcomes.
ABSTRACT
INTRODUCTION: Magnetic resonance cholangiopancreatography (MRCP) is an imaging technique that has advanced over the past few years. It still plays a crucial role in the study of numerous pancreaticobiliary diseases. This study aimed to evaluate the effects of hematinic syrup, date syrup, and pineapple juice on MRCP image quality. METHODOLOGY: This study involved a total of 90 participants, distributed evenly among three groups, with each group comprising 30 patients. Negative oral contrast solutions containing paramagnetic substances like Mn+2 and Fe+3, such as pineapple juice, date syrup, and hematinic syrup were imaged by 1.5 Tesla (T) magnetic resonance imaging (MRI) with T2-weighted (T2W) and MRCP sequences. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were computed. Ninety patients underwent MRCP 20-30 min after ingestion of 100 mL of date syrup, 30 ml of hematinic syrup diluted to 200 ml of water, and 200 mL of pineapple juice. MRCP images were taken to visualize various pancreaticobiliary structures (bile duct, stomach, and duodenum). RESULTS: The in vitro evaluation of the solutions showed that date syrup and hematinic syrup were hypointense in T2W sequences. The images obtained showed no significant difference in the CNR between the three solutions. However, the SNR was significantly higher for pineapple juice compared to date syrup and hematinic syrup in T2W and MRCP sequences. Images acquired post-administration of the oral contrast agents significantly improved the gastrointestinal tract signal suppression and increased visibility of the pancreaticobiliary structures (bile duct, stomach, and duodenum). No adverse events were observed among the participants. CONCLUSION: Pineapple juice was the best contrast agent. However, date syrup and hematinic syrup can also be used to improve the imaging quality.
ABSTRACT
Retrocaval ureter (RCU), also known as pre-ureteral vena cava or circumcaval ureter, is a rare congenital anomaly caused by inferior vena cava (IVC) dysgenesis, leading to the right ureter coursing behind the IVC. RCU results in obstructive proximal hydroureteronephrosis, remaining asymptomatic until the third decade when hydronephrosis develops. Diagnosis relies on imaging modalities like intravenous urography (IVU), ultrasonography, computed tomography urography (CTU), magnetic resonance urography, and nuclear scintigraphy. CTU provides comprehensive 3D evaluation. We report a novel case of a 50-year-old male with RCU complicated by a concurrent distal ureteral calculus. CTU demonstrated the characteristic "S-shaped" proximal ureteral deformity and its aberrant posterior course relative to the IVC, enabling accurate preoperative diagnosis. The co-occurrence of RCU with ureteral calculus is notably rare, underlining the necessity of an exhaustive diagnostic process. The patient successfully underwent a combined surgical intervention, consisting of laparoscopic ureteroureterostomy for RCU correction and ureteroscopic lithotripsy for calculus removal, showcasing a minimally invasive approach to simultaneously address both conditions. This report underscores the significance of advanced cross-sectional imaging in diagnosing RCU and demonstrates the effectiveness of integrated minimally invasive surgical techniques in treating complex urological anomalies. By documenting this case, we contribute to the broader understanding and awareness of RCU among clinicians, potentially guiding more prompt recognition and comprehensive management of this rare condition.
ABSTRACT
Swyer-James-Macleod syndrome (SJMS) or Bret syndrome presents as unilateral hyperlucent lung, an uncommon pulmonary condition. The accurate diagnosis of SJMS requires high-resolution CT (HRCT), as conventional chest radiographs may underestimate this condition. We present a case of SJMS in a 54-year-old male who was managed with bronchodilators and intravenous antibiotics. This case report underscores the rarity of SJMS in adulthood, with only a limited number of cases reported globally so far. Comprehensive use of HRCT is crucial for precise diagnosis, and early intervention with appropriate medical management is imperative for favorable outcomes.
