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Background: Chronic lung disease is frequently associated with lung vascular lesion. We evaluated the structural-functional related changes of right ventricle under CLD with or without PH at RSUP dr. Kariadi, Semarang. Methods: We studied patients at RSUP dr. Kariadi who underwent routine evaluation that included resting spirometry and echocardiography. Patients with either COPD or RLD were studied, exclusion were made for patients with valvular heart disease and congestive heart disease. This study was performed during May through June of 2019 (n = 20). PASP, RVD, RVWT, TAPSE and spirometry values were analyzed for the association between PASP and RVD, RVWT, TAPSE, TAPSE/PASP ratio and FVC, FEV1, FEV1/FVC. Results: Thirteen (65%) of 20 patients who underwent echocardiography and spirometry evaluation were male and their average age were 55 years old. Mean PASP was 49.30 mmHg (range 2–111 mmHg). Ninety five percents patients had restrictive spirometry and 5% patients had moderate-severe mixed spirometry. The majority of the population of the study sample is dominated by a very severe degree of restriction spirometry. Out of the 20 subjects, 15 subjects (75%) had a diagnosis of COPD and 10 subjects (50%) had a history of pulmonary TB. In this study, 75% subjects had right ventricular dilatation, 85% subjects had right ventricular hypertrophy, and 15% subjects had decreased right ventricular systolic function (low TAPSE). The majority of structural and functional abnormalities of the right heart are found on patients with very severe degree of restriction spirometry. There were 13 subjects (65%) pulmonary hypertension, with the most findings being severe pulmonary hypertension as many as 8 subjects (40%). As many as 14 subjects (70%) had high TAPSE / PASP ratio.Conclusions: PH prevalence in patients with CLD is significantly associated with spirometry values. PH severity degree in patients with CLD is not significantly associated with spirometry values.Key words: spirometry; pulmonary hypertension; right heart echocardiography.

Introduction Giant duodenal diverticulum is a very rare case. There are only few cases reported. We reported a case of giant duodenal diverticulum with biliary obstruction caused by mucinous carcinoma of distal common bile duct (CBD), that mimicking Lemmel syndrome. Case presentation A 68-years-old man admitted to hospital with recurrent epigastric pain, jaundice and fever. Magnetic resonance cholangiopancreatography showed dilated intrahepatic and extrahepatic biliary tree, dilated gallbladder and cystic mass in pancreatic head that pushed the pancreatic duct ventrally. Emergency laparotomy was performed. Distended edematous gallbladder with necrotic spot, dilated of CBD and compressible bulging of the pancreatic head were found. Duodenotomy in 2nd-3rd part was made and found a giant duodenal diverticulum filled with food and mucus. Tight adhesion to the ampula of Vater, common bile duct, and pancreas due to fibrosis, met difficulties in dissection with a lot of bleeding, hence the diverticulum was not removed. Gastrojejunostomy, cholecystectomy and choledocho-duodenostomy were also done. Pathologic examination of CBD mucus was accordance with mucinous carcinoma. Discussion Periampullary duodenal diverticulum can cause obstructive jaundice, known as Lemmel syndrome. This case was different as the giant duodenal diverticulum located in the 3rd part filled with food and mucin that compressed both distal CBD and pancreatic duct. The cause of obstructive jaundice could be fibrotic tissue in distal CBD and mucinous carcinoma. Conclusion Giant duodenal diverticulum with bile obstruction is very rare and challenging in diagnosis and treatment. The other cause of obstruction should be considered such as mucinous carcinoma of distal CBD.

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