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Diagnosis and treatment of Zollinger Ellison syndrome in a morbidly obese patient after Roux-en-Y gastric bypass

Published:September 01, 2010DOI:https://doi.org/10.1016/j.soard.2010.06.009
      Zollinger Ellison syndrome (ZES) is rare entity characterized by recurrent peptic ulcers due to high acid production from gastric parietal cells as a result of elevated secretion of the hormone gastrin [
      • Fendrich V.
      • Langer P.
      • Waldmann J.
      • Bartsch D.K.
      • Rothmund M.
      Management of sporadic and multiple endocrine neoplasia type 1 gastrinomas.
      ,
      • Zogakis T.G.
      • Gibril F.
      • Libutti S.K.
      • et al.
      Management and outcome of patients with sporadic gastrinoma arising in the duodenum.
      ,
      • Norton J.A.
      • Jensen R.T.
      Resolved and unresolved controversies in the surgical management of patients with Zollinger-Ellison syndrome.
      ,
      • Imamura M.
      • Komoto I.
      • Ota S.
      Changing treatment strategy for gastrinoma in patients with Zollinger-Ellison syndrome.
      ,
      • Khan R.N.
      • Bansal V.K.
      • Kumar S.
      • Jindal V.
      • Misra M.C.
      • Bhatia V.
      Duodenal gastrinoma: a diagnostic dilemma.
      ]. The abnormally high levels of gastrin are caused by a gastrin-secreting neuroendicrine tumor (gastrinoma) that frequently develops from the pancreas or from the first or second portion of the duodenum, in the denominated “gastrinoma triangle” [
      • Zogakis T.G.
      • Gibril F.
      • Libutti S.K.
      • et al.
      Management and outcome of patients with sporadic gastrinoma arising in the duodenum.
      ,
      • Norton J.A.
      • Jensen R.T.
      Resolved and unresolved controversies in the surgical management of patients with Zollinger-Ellison syndrome.
      ,
      • Imamura M.
      • Komoto I.
      • Ota S.
      Changing treatment strategy for gastrinoma in patients with Zollinger-Ellison syndrome.
      ,
      • Khan R.N.
      • Bansal V.K.
      • Kumar S.
      • Jindal V.
      • Misra M.C.
      • Bhatia V.
      Duodenal gastrinoma: a diagnostic dilemma.
      ]. Approximately 75% of ZES cases are sporadic, with the remaining 25% associated with multiple endocrine neoplasm type 1 [
      • Fendrich V.
      • Langer P.
      • Waldmann J.
      • Bartsch D.K.
      • Rothmund M.
      Management of sporadic and multiple endocrine neoplasia type 1 gastrinomas.
      ]. Approximately .1% of the patients with duodenal ulcers have evidence of ZES [
      • Fendrich V.
      • Langer P.
      • Waldmann J.
      • Bartsch D.K.
      • Rothmund M.
      Management of sporadic and multiple endocrine neoplasia type 1 gastrinomas.
      ]. The reported incidence of gastrinoma has been .5–4/1 million of the population annually [
      • Fendrich V.
      • Langer P.
      • Waldmann J.
      • Bartsch D.K.
      • Rothmund M.
      Management of sporadic and multiple endocrine neoplasia type 1 gastrinomas.
      ]. The incidence of marginal ulceration after Roux-en-Y gastric bypass (RYGB) has been reported at .8–2.6% [
      • Sacks B.C.
      • Mattar S.G.
      • Qureshi F.G.
      • et al.
      Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass.
      ,
      • Felix E.L.
      • Kettelle J.
      • Mobley E.
      • Swartz D.
      Perforated marginal ulcers after laparoscopic gastric bypass.
      ,
      • Lublin M.
      • McCoy M.
      • Waldrep D.J.
      Perforating marginal ulcers after laparoscopic gastric bypass.
      ]. Although the incidence of ZES in bariatric patients is unknown, ZES has frequently been considered in the differential diagnosis of a patient with refractory marginal ulcers. To our knowledge, no reports have been published describing the diagnostic algorithm and management of this infrequent, yet serious, condition in patients after RYGB. We present a case of ZES that developed 7 years after RYGB. A gastrinoma was suspected and identified. The patient underwent laparoscopic-assisted endoscopy and endoscopic ultrasonography (EUS), and the tumor was successfully resected by laparoscopy. The patient had an uneventful recovery.

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