MEDizzy - A 54-year-old man who has had a Billroth II procedure for

Feed Library Learning Discuss Leaderboard Journal

Metabolic diseases

A 54-year-old man who has had a Billroth II procedure for peptic ulcer disease now presents with abdominal pain and is found to have recurrent ulcer disease. The physician is considering this patient’s illness to be secondary either to retained antrum or to gastrinoma. Which of the follow- ing tests would best differentiate the two conditions?

ExplanationThe diagnosis of gastrinoma should be considered in all patients with recurrent ulcers after surgical correction for peptic ulcer disease, ulcers in the distal duodenum or jejunum, ulcer disease associated with diarrhea, or evidence suggestive of the multiple endocrine neoplasias (MEN) types I (familial association of pituitary, parathyroid, and pancreatic tumors) in ulcer patients. Because basal serum gastrin and basal acid production may both be normal or only slightly elevated in patients with gastrinomas, provocative tests may be needed for diagnosis. Both the secretin and calcium infusion tests are used; a paradoxical increase in serum gastrin concentration is seen in response to both infusions in patients with gastrinomas. In contrast, other conditions associated with hypergastrinemia, such as duodenal ulcers, retained antrum, gastric outlet obstruction, antral G cell hyperplasia, and pernicious anemia, will respond with either no change or a decrease in serum gastrin. Serum calcium level should be obtained to rule out concomitant hyperparathyroidism but would not help in the assessment of gastrinoma per se. Insulin-induced hypoglycemia is used as a provocative test for adrenal insufficiency, not for the evaluation of acid hypersecretory states.