A 45-year-old man comes to the physician due to epigastric pain and diarrhea. Past medical history is significant for peptic ulcer disease. He has a 20-pack-year smoking history but does not use alcohol or illicit drugs. Physical examination shows abdominal tenderness without rebound or rigidity. Endoscopy shows prominent gastric folds, 3 duodenal ulcers, and upper jejunal ulceration. Which of the following is the most appropriate next step in the management of this patient?

Question

A 45-year-old man comes to the physician due to epigastric pain and diarrhea.  Past medical history is significant for peptic ulcer disease.  He has a 20-pack-year smoking history but does not use alcohol or illicit drugs.  Physical examination shows abdominal tenderness without rebound or rigidity.  Endoscopy shows prominent gastric folds, 3 duodenal ulcers, and upper jejunal ulceration.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

11ec25c8_d408_1898_bc81_c566a1a61667_MD0003_00 This patient's clinical findings - recurrent peptic ulcer disease with multiple ulcers and jejunal ulceration - suggest gastrinoma (Zollinger-Ellison syndrome [ZES]). ZES is usually sporadic but is found in conjunction with multiple endocrine neoplasia type 1 (MEN1) in 20% of cases. Gastrinomas usually occur in patients age 20-50 with dyspepsia, reflux symptoms, abdominal pain, weight loss, diarrhea, or frank gastrointestinal bleeding. Endoscopy often shows thickened gastric folds, multiple peptic ulcers, refractory ulcers despite proton pump inhibitor (PPI) use, or ulcers distal to the duodenum in the jejunum (suggesting excess gastric acid that cannot be fully neutralized in the duodenum). Fasting serum gastrin level (off PPI therapy for 1 week) should be checked in suspected gastrinoma; a level <110 pg/mL rules it out, and a level >1000 pg/mL is strongly suggestive, although gastric pH should also be measured as gastrin may also be elevated due to failure of gastric acid secretion (achlorhydria). A gastrin level of 110-1000 pg/mL is nondiagnostic and requires a follow-up secretin stimulation test. Secretin inhibits gastrin release by normal gastric G cells but stimulates gastrin release by gastrinoma cells; therefore, secretin administration should not cause a rise in serum gastrin concentrations in patients with other causes of hypergastrinemia. Gastrinomas are managed with high-dose PPI, with surgery (eg, exploratory laparotomy and resection) considered in patients with sporadic gastrinoma with no evidence of metastatic disease. (Choice A) The calcium infusion study is usually reserved for patients who have gastric acid hypersecretion and are strongly suspected of having gastrinoma despite a negative secretin test. Calcium infusion can lead to an increase in serum gastrin levels in patients with gastrinoma. (Choice B) Jejunal ulcer biopsy would not likely be useful as jejunal ulcers are usually due to gastric acid hypersecretion rather than local tumor invasion. (Choice C) Serum chromogranin A is a marker for well-differentiated neuroendocrine tumors. It is elevated in several conditions such as carcinoid tumors, hyperthyroidism, chronic atrophic gastritis, and even chronic PPI therapy. For this reason, it is less sensitive and specific than measurement of serum gastrin level. However, it may be used as a confirmatory test in nondiagnostic cases. (Choice E) Triple therapy (PPI, amoxicillin, and clarithromycin) treats Helicobacter pylori infection, which can cause gastric and duodenal ulcers. However, this patient's diarrhea and multiple ulcers in different sites are more suggestive of gastrinoma. Educational objective: Gastrinoma (Zollinger-Ellison syndrome) should be suspected in patients with multiple stomach ulcers and thickened gastric folds on endoscopy. The diagnosis is strongly suggested by a fasting serum gastrin level >1000 pg/mL. Patients with nondiagnostic serum gastrin levels should be evaluated with a secretin stimulation test. References: Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors. (http://www.ncbi.nlm.nih.gov/pubmed/17985090)

A 45-Year-Old Man Comes to the Physician Due to Epigastric