The First Affiliated Hospital of Zhongshan University Chen Jie Cui Yi Wang Jinhui Xue Ling Li Ziping Chen Minhu[cases]The patient, male, 76
The First Affiliated Hospital of Zhongshan University Chen Jie Cui Yi Wang Jinhui Xue Ling Li Ziping Chen Minhu
The patient, male, 76 years old, due to repeated abdominal pain for more than 10 years, with diarrhea and vomiting for more than 3 years in December 2012 in the First Affiliated Hospital of Zhongshan University. No significant incentives in upper abdominal pain patients more than 10 years ago, with fasting and nocturnal, can alleviate after eating, no diarrhea, vomiting, hematemesis, melena, without belching, gastroscopy "duodenal ulcer", to "ray Bella with 10-20mg Qd after the treatment of abdominal pain, recurrent symptoms of withdrawal after then, long-term use of ray Bella with maintenance therapy. Patients with recurrent attacks of diarrhea, vomiting, abdominal pain, 3 years ago, in missed a day after Ray Bella with paroxysmal, watery, more than 10 times per day, with vomiting, stomach contents, no vomiting, vomiting coffee like substance, the degree of abdominal pain were worse than before, can relieve the regular use of thunder again Bella was. Before March visits to the local hospital, gastroscope prompt duodenal ulcer, serum gastrin 111.54pg/ml (34.5-91.8), abdominal CT showed no abnormalities, the local hospital suspected gastrinoma". Before January at the Zhongshan University Sun Yixian Memorial Hospital to check thyroid ultrasound of thyroid diffuse disease, thyroid nodules on both sides of the leaves. For further diagnosis and treatment to our hospital. Since the onset of the general situation, no significant change in body weight. More than 40 years ago, there was a history of duodenal ulcer bleeding; there was a history of hyperthyroidism in the past 3 years, the law took him methimazole 10mg Qd, the normal control of thyroid function.
Admitted to the hospital without special. After admission, blood routine, biochemical routine, including calcium 2.14mmol/L (2.10-2.60), a free power combination TSH 0.065 mIU/L (0.350-4.940), FT3 7.770 pmol/L (2.630-5.700), FT4 pmol/L (9.010-19.050) 14.760. Serum chromogranin A (CgA) 1074ng/ml (< 95ng/ml), gastrin 251.56 mu g/L (< g/L 100). Gastroscopy showed: 1, duodenal ulcer (scarring), HP (+); 2, duodenal descending junction lesions (Figure 1). Further endoscopic ultrasonography revealed a hypoechoic lesion located at the junction of the descending duodenal bulb with a size of about 0.5 x 0.6cm, a heterogeneous echo and a rich blood supply (Figure 2). Combined with endoscopic examination, a small lesion was seen in the corresponding part of the CT, and the enhancement was observed (Figure 3).
With "ray Bella with 10mg bid, lizhudele 220mg bid, 1g bid 0.5g bid, amoxicillin, clarithromycin" eradication of HP after 2 weeks of treatment, 2013-1-8 in the endoscopy center underwent endoscopic duodenal ball drop at the junction of submucosal tumor enucleation. The tumors originated from the muscularis propria, about the size of 0.6 * 0.6cm, circular, capsule integrity, depth of nearly serosa, intraoperative retained serosa full-thickness resection of submucosal tumor (Figure 4). Postoperative pathology showed that the tumor cells of the duodenum (duodenum) showed nests and adenoid hyperplasia, and the cell size was small. Immunohistochemically, the tumor cell CK (+), CgA (weak +), Syn (+), CD56 (+), NSE (+), M-CEA (small weak +), Ki-67 < 1%, Gastrin (+); the combination of clinical manifestations, HE morphology and immunohistochemical results, lesions consistent with gastrinoma G1 (Figure 5). After the operation, the patients were stopped by Rebela, and the symptoms of abdominal pain, diarrhea and vomiting were completely relieved. After 2 weeks, serum CgA 52ng/ml and gastrin were detected by g/L 128.91, which was significantly lower than that before operation.
Figure 1 Electronic Gastroscope: submucosal tumor of the duodenal bulb
Figure 2 endoscopic ultrasonography: submucosal lesions at the junction of the duodenal bulb
Figure 3: CT local hospital abdomen duodenal descending junction small uplift
Figure 4 endoscopic duodenal submucosal tumor enucleation of the junction drop
Figure 5 pathology: the tumor cells are nests and adenoid hyperplasia, the cell size is small, consistent with the neuroendocrine tumors.
[introduction of gastrin]
Gastrin (gastrinoma) is a rare functional neuroendocrine tumor with an annual incidence of only /100 (0.5-2). Excessive gastric acid secretion caused by excessive secretion of gastrin (Gastrin) in the tumor causes a series of acid related symptoms, which is characterized by intractable, multiple and recurrent peptic ulcer. Because of the earliest by Zollinger (Zollinger) and Alison (Ellison) reported in 1955, so the gastrinoma related symptoms and Zollinger Ellison syndrome (Zollinger - Ellison Syndrome, ZES).
Gastric cancer can occur at any age, with an average age of 48-55 years. About 75% of the patients were sporadic, with a family history of hereditary disease in I (MEN-1) in some patients. Typical clinical manifestations of multiple ulcer of upper digestive tract ulcer with atypical parts (duodenum, cross section or the proximal jejunum) and refractory ulcer after treatment for the characteristics, easy to relapse, and easy bleeding, perforation and obstruction. In addition to the typical symptoms of abdominal pain, often secretory characterized by watery diarrhea, acid suppression medications can alleviate immediate withdrawal recurrence. In addition, the majority of patients with acid reflux, heartburn and other symptoms of reflux esophagitis.
80%-90% of the tumor occurred in the stomach by the duodenum, the head of the pancreas and the liver of the twelve finger ligament composed of the triangle triangle (gastrinoma). In sporadic cases, occurred in the duodenum gastrinoma accounted for 50%-88%, while in MEN-1 twelve refers to the intestinal gastrin tumor accounted for up to 70%-100%, to see more bulb. MEN-1 is an autosomal dominant genetic disease, about 20%-30% of ZE syndrome in patients with MEN-1, the duodenal lesions were often multiple, so to have ZE syndrome, especially in patients with lesions in the duodenum, need to first except MEN-1 syndrome. About 25% of the tumors occurred in the pancreas, the rest of the rare parts of the stomach, liver, bile duct, ovary, etc.. Although the tumors are small and slow growing, they still have malignant potential, lymph node and distant metastasis, and poor prognosis.
For the diagnosis of gastric cancer, first of all, according to the typical clinical manifestations of patients with high gastric acid secretion, the characteristics of high blood glucose can be initially judged. Commonly used detection methods: PPI 1 weeks after stopping fasting serum gastrin (fasting serum gastrin, FSG), serum A (Chromogranin, CgA), gastric juice analysis. The normal blood calcium, no pyloric obstruction, normal renal function, FSG increased 10 times in the stomach and > pH < 2 can diagnose ZE syndrome; when increased the level of FSG is not enough to be diagnosed when secretin test (fasting all night, fasting, infusion of secretin in 2, 5, 10 15, the serum gastrin level after 30min), gastrin increased over baseline levels of 100 ng/L (healthy population gastrin rises higher than the baseline level 50%) can diagnose ZE syndrome, and this method can achlorhydric hypergastrinemia induced differentiation. Using multi-slice spiral CT or MRI, endoscopy and endoscopic ultrasound imaging for lesion and octreotide for diagnosis of gastrinoma, ultimately rely on pathological diagnosis.
Treatment, proton pump inhibitor (PPI) for the control of Zhuo AI syndrome, surgical resection of lesions is the main treatment. In the case of duodenal solitary gastrin tumor, local excision and regional lymph node dissection can be performed, and endoscopic resection can be used for endoscopic resection of small lesions (1cm). Postoperative serum CgA, CT or MRI is a reliable means of follow-up.
In this case, patients with recurrent peptic ulcer and diarrhea, effective treatment PPI, repeated withdrawal symptoms, serum CgA and gastrin was significantly increased, suggesting reduced duodenal submucosal lesions at the junction of endoscopic and imaging science, highly suspected gastrinoma. The serum calcium is normal, no abnormal parathyroid gland neck ultrasound imaging showed no evidence of tumor, pancreas, adrenal area may be considered, except MEN-1, sporadic gastrinomas. After complete dissection of the tumor under endoscope