Primary gastrin cell hyperplasia. Report of five cases and a review of the literature

Primary gastrin cell hyperfunction of the gastric antrum as a clinical syndrome consists of basal hypergastrinemia, an exaggerated gastrin response to feeding, the absence of any ectopic source of gastrin secretion, and peptic ulcer disease. The number of G-cells were quantitated in the gastric antrum of five patients with clinically diagnosed primary G-cell hyperfunction, and the results were compared to controls with a variety of gastric diseases. Patients with the clinical diagnosis of primary G-cell hyperfunction had a significantly increased number of antral G-cells (p less than 0.05). The clinical syndrome of primary G-cell hyperplasia appears to be associated with hyperplasia of G-cells rather than with the hypersecretion of gastrin by a normal number of G-cells.

Removal of gastrinomas for control of Zollinger-Ellison syndrome

There are two distinct problems in patients with Zollinger-Ellison Syndrome (ZES): peptic ulcer diathesis and malignant tumors. Antisecretory drugs have allowed us to control the ulcer symptoms and acid output in 45 patients with ZES. We report here the initial seven patients selected for surgical exploration with the goal of removing their gastrinomas. Prior to surgery, an extensive and rigorous protocol to localize the gastrinoma was carried out, including hypotonic duodenography, abdominal ultrasonography, selective arteriography, portal vein sampling for gastrin, and computerized tomography. With this protocol of radiographic localization, gastrinomas were found in two of the seven cases and the syndrome was "cured" in three of the seven patients. The results also demonstrate that preoperative localization is not a substitute for careful surgical exploration as tumors were found in two patients in whom localization failed.

Endoscopic diagnosis and removal of a duodenal wall gastrinoma

A 54-year-old man presented with unrelenting abdominal pain. An upper gastrointestinal x-ray showed a gastric ulcer. The duodenum showed minimal cap deformity suggestive of antecedent ulcer disease. The upper small intestine was within normal limits. Gastroduodenoscopy revealed a duodenal polyp. Biopsy of the polyp identified the presence of a gastrinoma. Serum gastrin level before endoscopic polypectomy was 489 pg/ml. Endoscopic polypectomy was performed and electron micrographs of the tissue revealed endosecretory granules of the gastrinoma. Complete removal of the gastrinoma was suggested by comparative gastric analyses, by serum gastrin levels of 93, 180, and 167 pg/ml, and by the clinical course.

[Gastrinoma: diagnosis and management of Zollinger-Ellison syndrome]

Diagnosis and management of Zollinger-Ellison syndrome (ZES) do not appear to be established even today. In the present study, 143 cases of ZES (including 12 of author's experience) were collected from Japanese literature and analyzed, and diagnosis and management were discussed. (1) Although 43% of patients showed high gastrin level (greater than or equal to 500pg/ml), it is worth to be stressed that gastrin level was below 300pg/ml in 29% of patients. (2) Secretin provocation test was essential for diagnosis and particularly useful for detecting ZES with low gastrin level. (3) Angiography and/or blood samplings of PTPC were widely used for localizing gastrinoma but the informations thus obtained were not always of help for complete removal of tumors since malignant or multiple gastrinomas were frequent. (4) An aim of management for ZES consists of complete removal of tumor but it is not always feasible. Therefore, removal of target organ (total gastrectomy) should be routinely added for long-term cure. (5) Value of chemical gastrectomy (H2-receptor antagonist) is still a matter of pros and cons but substantial value of this drug should be considered adjunct to surgery.

Secretin-induced gastrin response in the Zollinger-Ellison syndrome and chronic duodenal ulcer patients before and after cimetidine treatment

A secretin provocative test was performed in 16 patients with chronic duodenal ulcer and in five patients with the Zollinger-Ellison syndrome. In four chronic duodenal ulcer patients a second secretin test was done during acute iv cimetidine administration. There were only slight variations of gastrin compared with the first test. A third test was done on the same four chronic duodenal ulcer patients after 1 month's po cimetidine treatment (1 g/day); gastrin at 0 time was significantly higher than in the previous two tests (p less than 0.01). Integrated gastrin response after secretin was significantly lower in the third test than in the first (p less than 0.05). In two Zollinger-Ellison syndrome patients treated with 1.0 and 1.4 g/day cimetidine for 3 months, gastrin at 0 time was not markedly increased, whereas compared with the first test gastrin levels were higher at each time after secretin. These data suggest that previous cimetidine treatment does not alter, and may even increase, the diagnostic sensitivity of the secretin test.

Clinical relevance of regulatory gastrointestinal peptides

The application of radioimmunoassay of insulin, C-peptide, gastrin, glucagon, vasoactive intestinal polypeptides (VIP), somatostatin, human pancreatic polypeptides (hPP), substance P and neurotensin to detect endocrine tumors of the pancreas and other organ systems is undoubtedly important in the clinical management of patients suspected of having tumors that secrete these hormones. Radioimmunoassays of the above gut peptides have certain degrees of specificity and sensitivity; however, there are several factors that need to be considered in the interpretation of results since heterogeneity of molecular forms does occur and the varied radioimmunoassay techniques use different antibodies that may yield different results. It is, therefore, important that each laboratory establish its own normal values, determine the molecular species that each assay is detecting, and also determine the false positivity of the methodology. The same endocrine tumor may contain and secrete several detectable peptides, but the syndrome may relate to only one peptide. Although the simultaneous measurement of multiple peptides in patients with benign gastrointestinal disease has yielded information that contributes to our understanding of the complexities of gut neuroendocrine interaction, the pathophysiological role of gut peptides and their clinical relevance need further evaluation.

Peptic ulcer disease

Patients with peptic ulcer disease are commonly seen by family physicians. The incidence of duodenal ulcer seems to be declining in the United States. Avoidance of inciting factors and the use of antacids and cimetidine are indicated in the treatment of duodenal ulcers. New histamine H2 receptor antagonists and site-specific mucosal barrier agents are now available. Gastric ulcer differs from duodenal ulcer in many ways, and gastric carcinoma must be considered in the differential diagnosis. Other important entities include Zollinger-Ellison syndrome, "stress" ulceration, and peptic ulcer disease in children.

[Zollinger-Ellison syndrome]

The Zollinger-Ellison syndrome (ZES) is caused by mainly pancreatic, gastrin-producing tumours, which show a high rate of malignancy. The clinical picture is dominated by gastric hypersecretion, which results in the development of peptic ulcerations of the stomach and duodenum, reflux esophagitis, or diarrhea. The differentiation from other types of hypergastrinemia is done by provocative tests, mainly the secretin-test. Because of the high malignancy rate, therapeutically, a symptomatic treatment of gastric hypersecretion by H2-receptor antagonists or in cases of ineffective conservative treatment total gastrectomy is performed. In patients with duodenal gastrinomas or in the rare cases with benign pancreatic tumours resection of the tumours is the therapy of choice.

Multiple endocrine neoplasia syndromes

The multiple endocrine neoplasia (MEN) syndromes are characterized by autosomal dominant inheritance with a high degree of penetrance but varying expression. This review gives a classification of these syndromes and a short summary of the historical background. The pathogenesis of the disease and its possible origin in the APUD cell system are discussed together with the mechanisms underlying normal and ectopic hormone production by MEN tumors on the basis of recent findings in molecular endocrinology. The natural history and the clinical manifestations of the different syndromes are described. The sensitivity and discriminative capacity of the tests used to detect the syndromes in an early stage are compared. The choice of therapy and criteria for the timing and extensiveness of treatment are also considered. Lastly, problems associated with the ethical and legal aspects of screening, central registration, and monitoring of relatives at risk are described.

The diagnosis and management of gastrinoma

Initial reports of patients with Zollinger-Ellison syndrome were characterized by a long history of recurrent peptic ulcer and multiple operations. Diagnosis was usually made by a combination of clinical history and roentgenograms of the upper aspect of the gastrointestinal tract. Diagnosis was confirmed by the demonstration of elevated basal plasma gastrin levels. The management of the disease included either tumor excision or gastric resection, but more often it included a total gastrectomy. The mortality was high, often because of late recognition of the disease or operative problems related to inadequate control of the hypersecretion of acid. This review is a brief synopsis of the evolution and status of the different diagnostic and therapeutic techniques involved in the contemporary management of patients with gastrinomas. The diagnostic emphasis has shifted away from gastrointestinal contrast studies. Techniques have been developed both for the biochemical diagnosis of the condition and for the topographic localization of the site of the lesion. The use of acid secretory data has declined in value with the development of more elegant techniques for the detection of elevated levels of plasma gastrin in the systemic circulation and the use of portal venous sampling for identifying the source. Thus, the results of sophisticated procedures such as percutaneous transhepatic portopancreatic venous sampling or selective angiography provide additional information. The biochemical diagnosis of gastrinoma is best supported by the evaluation of provocative testing with either calcium or secretin rather than measurement of the basal levels of plasma gastrin. The introduction of potent H2 receptor antagonists has produced support for more conservative management of the disease. The incidence of significant complications during such therapy limits its over-all efficacy. The use of these drugs has, however, facilitated both the conservative and the operative management of patients with extensive sequelae of acid hypersecretion due to a gastrin-secreting tumor. It is probably reasonable to surgically stage the disease of all patients with hypergastrinemia of neoplastic origin since a small percentage (10 per cent) may have a solitary benign lesion which is curable by resection. Total gastrectomy under elective circumstances still has considerable merit. Preliminary data have indicated that alternative, lesser surgical procedures, such as proximal gastric vagotomy, may be therapeutic options if the patient is compliant and sensitive to the appropriate dosage of H2 receptor antagonist.(ABSTRACT TRUNCATED AT 400 WORDS)

Computed tomography and nuclear magnetic resonance imaging of pancreatic islet cell tumors

Eleven patients with pancreatic islet cell tumors smaller than 2.5 cm were examined by use of computed tomography (CT) and new scanning protocol. Seven of 11 tumors were localized and CT accurately assessed multiple lesions, retroperitoneal invasion, or liver metastases when present. CT is now the initial imaging procedure of choice for diagnosis and staging of islet cell tumors. Nuclear magnetic resonance can distinguish islet cell tumors from normal retroperitoneal structures and appears to be a promising new pancreatic imaging modality.

Diagnosis and management of the Zollinger-Ellison syndrome

In the last 10 years, the basis for the diagnosis and treatment of gastric hypersecretion in Zollinger-Ellison syndrome has changed dramatically. The diagnostic criteria have changed because gastrin hypersecretion by a non-beta islet tumor is now known to be responsible for gastric hypersecretion, and gastrin radioimmunoassays are now widely available. The treatment of the gastric hypersecretion in Zollinger-Ellison syndrome has changed since development of histamine H2-receptor antagonists and the demonstration that gastric acid secretion can be controlled medically in most patients, obviating routine total gastrectomy. In this paper, we review currently available and newer antisecretory drugs, the results of long-term medical treatment, potential problem areas, and our current approach to controlling gastric hypersecretion in patients with Zollinger-Ellison syndrome.

Radioimmunoassay of gastrin--our experience and a review of current status

The procedures of radioimmunoassays for gastrin are presented in this paper. Techniques are described and evaluated with special reference to preparation of radioiodinated gastrin, purification of monoiodinated gastrin, characterisation of the immunochemical properties of radiolabelled gastrin, raising and characterisation of specific antibodies, incubation conditions, separation of bound and free hormone and treatment of data. Factors contributing to discrepancies of radioimmunoassay results and problems encountered are discussed. Methods employed by the authors in gastrin radioimmunoassay are described. Commercially available gastrin kits are also compared.

Recurrent ulcer after gastric surgery--prevention and management based on a local experience

This paper reports a personal experience in the management of 45 patients with recurrent ulcer after gastric surgery. Inadequate acid reduction was the major cause of ulcer recurrence and treatment was by further acid reduction. Revisional surgery was performed in 23 patients (including a patient with a gastro-jejuno-colic fistula) with one mortality. Preliminary results of therapy with histamine H2-receptor antagonists have been encouraging and there appears to be a reduced need for re-operation in these patients in recent years. Less common causes of ulcer recurrence include retained suture material (2 cases) and the Zollinger-Ellison syndrome (2 cases). The incidence of post-surgical ulcer recurrence may be reduced by: improved surgical techniques, particularly in the performance of vagotomy, and avoidance of operations without acid reducing procedures e.g., gastro-jejunostomy without vagotomy; wider use of emergency ulcer curative surgery for perforated peptic ulcer. Experience at two local centres has been that this is a safe procedure in selected patients, there being no mortality in 58 cases. Routine screening of peptic ulcer patients for the Zollinger-Ellison Syndrome by measuring the serum gastrin level facilitates early diagnosis of the condition, thus forestalling gastric surgery and the inevitable recurrent ulceration.