Case Study: Managing Zollinger-Ellison Syndrome – A Multifaceted Approach
Patient Information: Name: Mr. John Doe Age: 45 years Gender: Male Presenting Complaint: Chronic abdominal pain, recurrent peptic ulcers, diarrhea
Case Presentation: Mr. John Doe presented to the gastroenterology clinic with complaints of chronic abdominal pain, recurrent episodes of peptic ulcers, and diarrhea over the past year. His symptoms had not responded adequately to over-the-counter antacids and proton pump inhibitors (PPIs), prompting further evaluation. His medical history was unremarkable, and he denied any significant alcohol intake or NSAID use. Family history was negative for gastrointestinal disorders.
Clinical Assessment: On physical examination, Mr. Doe appeared generally well-nourished with no signs of acute distress. Abdominal examination revealed epigastric tenderness without guarding or rebound tenderness. Laboratory investigations revealed an elevated fasting gastrin level of 1200 pg/mL (normal range: 0-100 pg/mL) and evidence of gastric acid hypersecretion. Upper endoscopy confirmed the presence of multiple duodenal ulcers with surrounding erythema and friability.
Diagnostic Workup: Further evaluation with imaging studies, including computed tomography (CT) and somatostatin receptor scintigraphy (SRS), was conducted to localize the suspected gastrinoma. CT scan revealed a small pancreatic mass suspicious for a neuroendocrine tumor, while SRS demonstrated increased radiotracer uptake in the region of the pancreatic head. Endoscopic ultrasound (EUS) confirmed the presence of a 2 cm mass in the pancreatic head consistent with a gastrinoma.
Diagnosis: Based on the clinical presentation, laboratory findings, and imaging studies, a diagnosis of Zollinger-Ellison Syndrome (ZES) secondary to a pancreatic gastrinoma was established.
Management Plan: A multidisciplinary approach involving gastroenterologists, endocrinologists, surgeons, and oncologists was initiated to manage Mr. Doe’s condition effectively.
- Medical Therapy:
- Mr. Doe was started on high-dose proton pump inhibitors (PPIs) to suppress gastric acid secretion and promote ulcer healing.
- Symptomatic management of diarrhea with antidiarrheal medications was implemented.
- Surgical Intervention:
- Given the localization of the gastrinoma to the pancreatic head and absence of metastatic disease, surgical resection was deemed appropriate.
- Mr. Doe underwent pancreaticoduodenectomy (Whipple procedure) to remove the gastrinoma along with the affected pancreatic tissue.
- Postoperative Follow-up:
- Following surgery, Mr. Doe’s symptoms improved significantly, and his gastrin levels normalized.
- Regular surveillance with biochemical markers and imaging studies was planned to monitor for disease recurrence.
- Long-Term Considerations:
- Genetic counseling and screening were offered to Mr. Doe to assess for familial syndromes such as multiple endocrine neoplasia type 1 (MEN1).
- Endoscopic surveillance for ulcer recurrence and dysplasia was recommended at regular intervals.
Outcome: Mr. Doe’s postoperative course was uneventful, and he remained asymptomatic during follow-up visits. Serial imaging studies showed no evidence of tumor recurrence, and his gastrin levels remained within normal limits. He resumed his normal activities and reported a significant improvement in his quality of life following successful management of ZES.
Conclusion: This case highlights the importance of a comprehensive approach to the diagnosis and management of Zollinger-Ellison Syndrome. Through collaboration between different specialties, including gastroenterology, endocrinology, surgery, and oncology, effective control of symptoms and improvement in patient outcomes can be achieved. Early recognition of ZES, accurate localization of gastrinomas, and timely intervention are crucial for optimizing long-term outcomes and quality of life in affected individuals.
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