A 45-year-old man comes to the emergency department after an episode of coffee-ground emesis. During the past 6 months, he has had intermittent abdominal pain and heartburn partially relieved by over-the-counter antacids. The patient also complains of explosive diarrhea that has not responded to dietary modifications. Two months ago, he stopped consuming milk without relief. He is a lifetime nonsmoker.
His blood pressure is 133/70 mm Hg and pulse is 89/min. There are no orthostatic changes. He has moderate epigastric tenderness without rebound.
Laboratory results are as follows:

Upper gastrointestinal endoscopy shows 2 small ulcers in the duodenal bulb with clean bases and a 1.2-cm ulcer in the very proximal jejunum.
Which of the following is most likely to establish the diagnosis in this patient?

Question

A 45-year-old man comes to the emergency department after an episode of coffee-ground emesis.  During the past 6 months, he has had intermittent abdominal pain and heartburn partially relieved by over-the-counter antacids.  The patient also complains of explosive diarrhea that has not responded to dietary modifications.  Two months ago, he stopped consuming milk without relief.  He is a lifetime nonsmoker.
His blood pressure is 133/70 mm Hg and pulse is 89/min.  There are no orthostatic changes.  He has moderate epigastric tenderness without rebound.
Laboratory results are as follows:

Upper gastrointestinal endoscopy shows 2 small ulcers in the duodenal bulb with clean bases and a 1.2-cm ulcer in the very proximal jejunum.
Which of the following is most likely to establish the diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_960b_dc5d_853d_316b0c4e68c6_MD0002_00 This patient's presentation and endoscopic findings suggest gastrinoma (Zollinger-Ellison syndrome), which can be sporadic or found in conjunction with multiple endocrine neoplasia type 1 (MEN-1) in 20% of cases. Gastrinomas usually present in patients age 20-50 with dyspepsia, reflux symptoms, abdominal pain, weight loss, or frank gastrointestinal bleeding. Endoscopy often shows thickened gastric folds, multiple peptic ulcers, refractory ulcers despite proton pump inhibitor use, or ulcers distal to the duodenum in the jejunum. The gastrin level should be checked in suspected gastrinoma; a level < 110 pg/mL rules it out. A gastrin level > 1000 pg/mL is highly suggestive and requires checking the gastric pH, with pH > 4 ruling out gastrinoma. A pH < 4 suggests gastrinoma and requires further testing (eg, endoscopic ultrasound, somatostatin receptor scintigraphy, and CT or MRI) for localization. < A gastrin level of 110-1000 pg/mL requires a follow-up secretin stimulation test. A negative secretin test rules out gastrinoma; a positive test requires further localization testing. Gastrinoma associated with MEN-1 syndrome usually responds to proton pump therapy. However, surgery is usually preferred for sporadic gastrinomas or MEN-1 patients with uncontrolled symptoms on medical therapy. (Choice A) Gastrinoma occurs most commonly (~ 70%) in the duodenum and less commonly in the head of the pancreas and surrounding lymph nodes. Jejunal ulcer biopsy would not be as useful as the ulcers are due to surrounding acid hypersecretion rather than local tumor invasion. (Choice B) Triple therapy (proton pump inhibitor, amoxicillin, and clarithromycin) treats Helicobacter pylori, which can cause gastric and duodenal ulcers. However, this patient's multiple ulcers in different sites and diarrhea are more suggestive of gastrinoma. (Choice C) Serum 5-hydroxyindoleacetic acid is a serotonin metabolite elevated in carcinoid tumor, which usually presents with chronic diarrhea and flushing instead of gastrointestinal ulcers. (Choice E) Serum tryptase is released from mast cells and is elevated in both cutaneous and systemic mastocytosis. Patients with mastocytosis usually present with chronic abdominal pain, diarrhea, anaphylaxis or allergic-like reactions, hypotension, flushing, pruritus, syncope, fatigue, and headaches. Educational objective: Gastrinoma should be suspected in patients with multiple stomach ulcers and thickened gastric folds on endoscopy. The diagnosis is strongly suggested by serum gastrin level > 1000 pg/mL and gastric pH < 4.0. Endoscopic ultrasound, somatostatin receptor scintigraphy, and CT or MRI imaging can localize and stage the gastrinoma. < __________ References: Management of sporadic and multiple endocrine neoplasia type 1 gastrinomas. (http://www.ncbi.nlm.nih.gov/pubmed/17939142) Gastrinoma. (http://www.ncbi.nlm.nih.gov/pubmed/12057114)

A 45-Year-Old Man Comes to the Emergency Department After an Episode