Lemmel syndrome is a rare clinical entity characterized by the presence of a periampullary duodenal diverticulum resulting in compression and dilatation of the pancreatic and common bile ducts, accompanied by obstructive jaundice. Gastric outlet obstruction is not a known complication of this syndrome, and there are no standardized approaches to its treatment. We present the first case of Lemmel syndrome presenting as gastric outlet obstruction and provide the results of a systematic literature review.

eosinophils (Figure). The working diagnosis was peptic stricture with possible eosinophilic esophagitis (EoE). He was started on pantoprazole 40 mg twice daily. He underwent 2 more EGDs with dilation for recurrent stricture and on the 2nd EGD, biopsy of the stricture showed numerous intraepithelial lymphocytes and focal apoptotic squamous cells (Civatte bodies) compatible with ELP. Budesonide slurry 1 mg twice daily was instituted and an EGD 6 months later showed near resolution of the stricture. The patient no longer requires dilations or antiacid therapy and is asymptomatic currently. He had Candida esophagitis 1 month after initiation of budesonide which was treated with fluconazole. Discussion: ELP is prevalent in patients with mucocutaneous forms of LP, most often oral LP. It is rarely seen in males with a case series by Franco et al describing the female to male ratio as 5:1. The endoscopic differential diagnosis for ELP should distinguish findings of esophagitis and stricture secondary to EoE, reflux esophagitis or esophageal Candidiasis. A low threshold should be kept for suspecting ELP in a patient with dysphagia and mucocutaneous LP. If histology is inconclusive but a high index of suspicion remains, particularly in patients with mucosal LP, repeating biopsies may be warranted for diagnosis as is highlighted in this case. A co-relation between longer duration of disease with severity of inflammation has been proposed with case series reporting strictures. Treatment includes serial dilations, topical and/or systemic steroids. Recurrence has been described despite topical steroid therapy with requirement of additional dilations. Successful use of immunomodulators such as cyclosporine, mycophenolate has been described. There is paucity of data regarding surveillance and optimal treatment for ELP, and thus further studies are needed for better understanding of this disease.[2440] Figure 1. Esophageal biopsy showing esophageal squamous mucosa with basal cell hyperplasia, intraepithelial lymphocytes, and 2 apoptotic keratinocytes (Civatte or colloid bodies). Findings are compatible with esophageal lichen planus.