The Early Diagnosis of Gastrinoma

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Abstract
Despite the increasing awareness of gastrinoma and its lethal peptic ulcer sequelae, the diagnosis is often initially missed or made as a terminal event. All patients with peptic ulcer symptoms serious enough to warrant hospital admission or those associated with diarrhea, nephrolithiasis, hypercalcemia or pituitary abnormality were screened. In a 1-yr period (1979-1980), 9 of 14 suspected new gastrinoma patients were identified using a sensitive and specific gastrin radioimmunoassay in combination with provocative tests including i.v. secretin, calcium and food. Conventional upper GI [gastrointestinal] series, CAT [computed axial tomography] scan, arteriography and endoscopy provided no additional information other than to confirm the presence of ulcer disease. Basal plasma gastrin levels were > 200 pmol l-1 in only 3 of the 9 (normal fasting plasma gastrin levels are < 25 pmol l-1). Three patients presented with acute ulcer perforation, and the diagnosis of gastrinoma was suspected because of multiple ulcers and pancreatic masses. In 3 other patients, previous duodenal ulcer surgery had failed. One patient with dyspepsia, high basal plasma gastrin, negative secretin and Ca infusion studies, and a positive meal test was diagnosed as having G-cell hyperplasia; this was confirmed by biopsy and antral gastrin extraction. Antrectomy alone resulted in cure. In all patients tested, a positive Ca infusion or secretin bolus (> 100% rise over basal) strongly suggested the diagnosis of gastrinoma, which was confirmed at surgery. In the acute perforations, initial management with omental patch and cimetidine therapy allowed survival of 2 patients, while emergency total gastrectomy in the 3rd resulted in death due to esophagojejunal leak. Elective patients were treated with cimetidine initially for at least 2 weeks before total gastrectomy. In this group there were no operative mortalities, and postoperative morbidity was minimal. This series illustrates 3 important points; careful screening of an ulcer population using gastrin radioimmunoassay and provocative tests has enabled a high yield of gastrinomas while conventional investigations are of minimal value; a high index of suspicion in appropriate cases is necessary; and total gastrectomy performed under elective circumstances is safe and allows the patients to resume a normal and healthy life without the sequelae of aggresive peptic ulceration or daily drug administration.