S6153 Unexplained Jejunal Ulcers and Bleeding: A Case of Duodenal Gastrinoma Confirmed by Secretin Challenge

Introduction: Zollinger Ellison syndrome (ZES) involves excessive gastric acid production, leading to peptic ulcers and persistent diarrhea. ZES are linked to hypergastrinemia from gastrinomas, typically located in “gastrinoma-triangle” bordered by pancreatic head and duodenal sweep. Around 80% are sporadic, while 20 to 30% are linked to MEN 1. Surgical resection of these neuroendocrine tumors are recommended, nonetheless, the gastroenterologist need to confirm diagnosis and guide the surgeon towards their anatomical location. We present a case highlighting these keys concepts in the management of ZES. Case Description/Methods: A 62-year-old woman with multiple duodenal and jejunal ulcers complicated by jejunal perforation underwent an exploratory laparotomy, small bowel resection and duodenojejunal (DJ) anastomosis. She continued to have GI bleeding with hemoglobin 9.3 g/dl which raised the suspicion of ZES. Patient was not exposed to nonsteroidal anti-inflammatory drug and H pylori stool antigen was negative. Upper endoscopy demonstrated more than twenty clean based ulcers in duodenum as well as large ulcers in jejunum. D-J anastomosis was intact and normal. A gastrin level was checked off proton pump inhibitor (PPI) and was 347 pg/ml. Computed tomography Abdomen with contrast did not show any etiology for multiple peptic ulcer disease. Discussion: Zollinger-Ellison syndrome (ZES) is exceedingly rare, with an estimated annual incidence of 0.1–3 cases per million population. It is caused by excess gastrin secretion from gastrinomas, usually in the duodenum or pancreas. Symptoms include peptic ulcers, heartburn, diarrhea, and weight loss. Diagnosis involves fasting serum gastrin and gastric pH; a gastrin >1000 pg/mL with pH <2 is diagnostic. Secretin or calcium infusion tests are used if inconclusive. Imaging (computed tomography, MRI, EUS, 68Ga-DOTATATE PET) helps localize tumors. PPIs are first-line; somatostatin analogs may help. Surgery is recommended for localized sporadic gastrinomas. In MEN1, surgery is less often curative, and its role remains controversial.