Gastrinoma

The unusually severe course of duodenal ulcers associated with a pancreatic tumor was noted as early as 1901, but it was only in 1955 that this combination was identified as an independent syndrome, called ulcerogenic ulcerative diathesis syndrome (or, according to the authors who described it, Zollinger-Ellison syndrome).

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Causes gastrinomas

At present, there are reports of approximately 500 patients with proven tumor nature of ulcerogenic syndrome. The disease is based on hypergastrinemia. The latter causes constant stimulation of the function of the parietal cells of the stomach. Gastric hypersecretion with a very high concentration of hydrochloric acid causes most manifestations of the syndrome and, first of all, ulceration of the mucous membrane of the gastrointestinal tract.

Most often, the ulcer is localized in the postbulbar section of the duodenum, although it is observed from the esophagus to the ileum. Almost a quarter of patients have multiple ulcers. Their tendency to recurrence is also associated with gastric hypersecretion, even after vagotomy and multiple surgeries on the stomach (peptic ulcers of the anastomosis). Another feature of the disease is a higher frequency of complications than in ordinary peptic ulcer disease: bleeding, perforation, stenosis. Almost all patients have severe pain syndrome. Changes in pH in the upper sections of the small intestine due to the massive influx of acidic contents from the stomach leads to the development of diarrhea, and inactivation of pancreatic and intestinal enzymes leads to steatorrhea.

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Symptoms gastrinomas

The symptom complex of ulcerogenic syndrome may be the result of hyperplasia of G-cells of the antrum of the stomach, which is called "pseudo-Zollinger-Ellison syndrome". More than 60% of gastrinomas are malignant, most of which metastasize. In almost 40% of patients, gastrinoma is part of the syndrome of multiple endocrine neoplasia type I. Adenomas of the parathyroid glands are most often detected.

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Diagnostics gastrinomas

Gastric juice examination largely determines the diagnosis of gastrinoma. Patients with ulcerogenic syndrome are characterized by 12-hour nocturnal secretion of hydrochloric acid - more than 100 mEq and hourly basal - more than 15 mEq.

Another indicator is the ratio of hourly basal secretion to hourly histamine-stimulated secretion of HCl, which in most patients exceeds 0.6. Of particular diagnostic importance is the secretion of immunoreactive gastrin. If its level is more than 300 ng/ml, there is a high probability of gastrinoma.

Radiologically, in addition to an ulcer of one or another localization, coarse folding of the gastric mucosa caused by its hyperplasia and a large amount of gastric contents are always revealed. For the purpose of topical diagnosis of gastrinomas, angiographic method can be used, but it is effective in slightly more than half of patients. A feature of gastrinomas is their often multiple nature and ectopic location, usually in the wall of the stomach and duodenum, near the pancreas itself.

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Treatment gastrinomas

Treatment of Zollinger-Ellison syndrome is surgical. Regardless of detection or removal of gastrinoma, gastrectomy is considered the operation of choice, the purpose of which is to eliminate the effector organ, since there is never certainty of complete removal of tumor tissue or the absence of metastases. Drug treatment of gastrinoma is ineffective. The use of antacids and anticholinergics only alleviates the symptoms. Recently, the histamine H2-receptor antagonist metiamide has been used with good results.