A Challenging case of Gastrinoma
Ahmed Imran Siddiqi, University College London
Gastrinomas are tumours of pancreas or duodenum secreting excessive gastrin leading to acid hyper-secretion in stomach causing ulcer, perforations and diarrhoea.
A 77 years old non-smoker lady had been suffering from gradually worsening bouts of severe watery diarrhoea and vomiting for previous ten years and 6 stones weight loss. Frequency of bouts had recently increased occasionally associated with abdominal pain, flushing, severe retching, heart burns with multiple vomiting episodes and feeling hot but no fever. Her medications (omeprazole, ranitidine, creon) were of no help. She had a laparotomy for perforated anterior jejunal wall three years ago. Her BP was 152/86 mm/Hg, no lymphadenopathy and mild tenderness around her epigastrium. Multiple endoscopies showed gastritis and duodenitis, biopsy confirmed oesophageal gastric metaplasia, chronic duodenitis and intestinal metaplasia of stomach. Gastrin was mildly raised a few times; faecal elastase was very low suggesting exocrine pancreatic dysfunction. Urinary 5HIAA, TTG, selenium, zinc and C1 elastase inhibitor, thyroid function test were all normal. Small bowel meal and CT abdomen showed no abnormality except thickened lower oesophagus. Secritin stimulation test confirmed gastrinoma. Her gallium dotatate PET scan, octreotide scan and endoscopic ultrasound showed a nodule between stomach and head of pancreas which was resected but Gastrin levels remained high following surgery but the bouts of diarrhoea reduced considerably. Short acting octreotide relieved all the symptoms and remains well controlled on long acting octretide now.
Patients with these rare tumors require systematic stepwise approach. Cure if often not achieved but significant improvement in symptoms is still very rewarding.