University of Arizona College of Medicine Phoenix, AZ, United States
Sakolwan Suchartlikitwong, MD1, Nael Haddad, MD2, Paul Muna Aguon, MD1, Kelly Zucker, DO1, Brian M. Fung, MD1, Hugo Pinillos, MD3 1University of Arizona College of Medicine, Phoenix, AZ; 2University of Arizona, Phoenix, AZ; 3Carl T. Hayden VA Medical Center, Phoenix, AZ
Introduction: Gastrinomas are one of several types of neuroendocrine tumors in the gastrointestinal (GI) tract. We report an unusual case of a patient with a gastrinoma, initially presenting with symptoms of global GI dysmotility.
Case Description/Methods: This is a 63-year-old male who presented with abdominal pain, nausea, vomiting, and melena. His hemoglobin level was 7.7 g/dL. Upper endoscopy was performed revealing a 13 mm ulcer with pigmented spot in the duodenal bulb. The stomach mucosa was noted to be thickened in the cardia and body, and difficulty with insufflation was noted. Gastric biopsies showed chronic active gastritis with negative helicobacter stain. His hospitalization was prolonged due to intestinal distension which improved after nasogastric tube decompression. He had 3 additional hospital admissions for abdominal pain and distension, each of which improved after nasogastric and colonic decompression. During his fourth admission, he experienced brisk upper GI bleeding. An urgent upper endoscopy showed a 2 cm bleeding ulcer in the duodenal bulb, several clean-based ulcers in the gastric antrum and duodenal bulb, and two 7-8 mm nodules in the duodenal bulb. Although he was already on a proton pump inhibitor treatment for peptic ulcer disease, a gastrin level was checked and was 158 pg/mL. A copper CU-64 dotatate scan revealed a 0.5 x 1.8 cm soft tissue density with an increase-uptake adjacent to the pancreatic head and enlarged aortocaval and portal hepatis lymph nodes. A subsequent endoscopic ultrasound showed no discrete mass at the head of pancreas. Tissue was obtained from enlarged lymph nodes and from nodules in the duodenal bulb. Pathology revealed a well-differentiated WHO grade 2 neuroendocrine tumor. He underwent a Whipple procedure, and gross pathology confirmed metastatic gastrinoma to regional lymph nodes.
Discussion: Common manifestations of gastrinomas include peptic ulcer disease, diarrhea, weight loss, and heartburn. About 1-10% of gastrinomas can be part of multiple endocrine neoplasia type 1 and can have hormonal symptoms related to the syndrome. However, GI dysmotility without mechanical obstruction, known as chronic intestinal pseudo-obstruction (CIPO), together with gastrinoma, is rare. To the best of our knowledge, only cases of bronchial neuroendocrine tumors and CIPO have previously been described. Treatment of the neuroendocrine tumor results in improvement and resolution of CIPO.
Figure: A Picture demonstrates a bleeding duodenal ulcer (on the left) and thickened gastric fold on retroflexion view (on the right)
Disclosures: Sakolwan Suchartlikitwong indicated no relevant financial relationships. Nael Haddad indicated no relevant financial relationships. Paul Muna Aguon indicated no relevant financial relationships. Kelly Zucker indicated no relevant financial relationships. Brian Fung indicated no relevant financial relationships. Hugo Pinillos indicated no relevant financial relationships.
Sakolwan Suchartlikitwong, MD1, Nael Haddad, MD2, Paul Muna Aguon, MD1, Kelly Zucker, DO1, Brian M. Fung, MD1, Hugo Pinillos, MD3. P0944 - Chronic Intestinal Pseudo-Obstruction: A Rare Entity Related to Gastrinoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.