Harbor UCLA Medical Center Las Vegas, NV, United States
Jenny Hong, MD1, Marwan Mashina, MD2, Annie Hong, MD3, Yousif Elmofti, MD3, Jose Aponte-Pieras, MD2, Muhammad T. Farooqui, MD3, Wen Yuan Yu, MD4, Gordon V. Ohning, MD5 1Harbor UCLA Medical Center, Las Vegas, NV; 2University of Nevada School of Medicine, Las Vegas, NV; 3University of Nevada Las Vegas, Las Vegas, NV; 4University of Nevada Las Vegas School of Medicine, Las Vegas, NV; 5University of Nevada Las Vegas, School of Medicine, Las Vegas, NV
Introduction: Gastrinomas are a rare neuroendocrine tumor that predominantly secretes gastrin and leads to peptic ulcer disease, acid reflux, and malabsorption. Diagnosis is usually made by gastrin levels and secretin stimulation test (SST). Here, we present a case of gastrinoma diagnosed by endoscopic ultrasound (EUS).
Case Description/Methods: 49 year old female with chronic pancreatitis secondary to alcohol presented for syncopal episode. She noted melena for the last 4 days, with a similar episode 2 years ago found to have “bad stomach ulcers”, but with no follow-up. She was transfused blood and started on PPI upon arrival. Upper endoscopy showed thickened gastric folds and extensive ulceration from duodenum to jejunum suggestive of gastric acid hypersecretion. Further work up showed gastrin 436 and gastric acid pH 1-2. Due to concern for outpatient follow-up, octreotide scan was done which was negative. We proceeded to EUS with the patient’s consent, which showed atrophic pancreas with calcification throughout, and a 2-3 cm focal parenchyma devoid of calcification suspicious for mass from which fine needle aspiration (FNA) was performed. Pathology confirmed a well-differentiated neuroendocrine tumor. Patient was continued on PPI and referred outpatient for surgical resection.
Discussion: The screening criteria of gastrinoma is fasting gastrin level > 1000 pg/mL and gastric pH < 2. SST can confirm diagnosis for those without active severe manifestations due to risks of stopping PPI in these patients. For localization, Ga-68 dotatate PET CT is the most sensitive test while octreotide scan has lower sensitivity and specificity. If these are unsuccessful, EUS and exploratory laparotomy may be considered.
In this case, our patient was difficult to diagnose. Her clinical and endoscopic findings were highly suggestive of gastrinoma, however her initial tests were inconclusive and an SST was unable to be performed due to her acute presentation. With our endoscopy team, a suggestive pancreatic lesion was biopsied and confirmed the diagnosis. EUS is a relatively low risk procedure that allows for FNA as an alternative to diagnose gastrinomas. Studies have found that EUS has high sensitivity for detection and localization, particularly for pancreatic tumors, and can detect even small tumors. Therefore, EUS can be an effective and safe method to diagnosis that can lead to definitive treatment.
Figure: Figure 1. (a) Numerous large, circumferential duodenal ulcers on EGD. (b) Ulcer extension to the jejunum on EGD. (c) Atrophic calcified pancreas with focal area devoid of calcifications between pancreatic neck and body on EUS. (d) H&E showing polygonal cells with round, regular nuclei. (e) Synaptophysin positivity for neuroendocrine differentiation supporting gastinoma.
Disclosures: Jenny Hong indicated no relevant financial relationships. Marwan Mashina indicated no relevant financial relationships. Annie Hong indicated no relevant financial relationships. Yousif Elmofti indicated no relevant financial relationships. Jose Aponte-Pieras indicated no relevant financial relationships. Muhammad Farooqui indicated no relevant financial relationships. Wen Yuan Yu indicated no relevant financial relationships. Gordon Ohning indicated no relevant financial relationships.
Jenny Hong, MD1, Marwan Mashina, MD2, Annie Hong, MD3, Yousif Elmofti, MD3, Jose Aponte-Pieras, MD2, Muhammad T. Farooqui, MD3, Wen Yuan Yu, MD4, Gordon V. Ohning, MD5. P2779 - A Case of Pancreatic Gastrinoma Diagnosed by Endoscopic Ultrasound, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
