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Liver & GIT

Question
25 out of 27
 

Best screening test for ZES? (LQ)



A Calcium infusion test
B Secretin injection

C BAO/MAO ratio
D CT abdomen

Ans. B Secretin injection

Zollinger-Ellison syndrome (Ref. Hari-18th ed., Pg. 2454)

1. A non-beta islet cell tumor that produces gastrin and is associ­ated with gastric acid hypersecretion and peptic ulcer disease.

2. The tumors are biologically malig­nant in 60% of cases.

3. Tumor size varies from 2 mm to 20 cm.

4. Tumor Distribution

a. Most common site is duodenum. Majority of gastrinomas occurred within Hypothetical gastrinoma triangle (confluence of the cystic and common bile ducts superiorly, junction of the second and third portions of the duodenum inferiorly, and junction of the neck and body of the pancreas medially.

b. Second most common site is pancreas.

Clinical Manifestations:

1. Peptic ulcer

a. Duodenal bulb

b. Unusual locations (second part of the duodenum and beyond).

c. Ulcers refractory to standard medical therapy

d. Ulcer recurrence after acid-reducing surgery

e. Ulcers in the absence of H. pylori or NSAID ingestion.

2. Diarrhea

3. Presence of MEN I

Diagnosis of ZES: Fasting gastrin level.

Fasting gastrin levels are usually <150 pg/mL. Virtually all gastrinoma patients have a gastrin level > 150-200 pg/mL.

Extra Edge Other causes of elevated fasting gastrin level.

1. Gastric hypochlorhydria or achlorhydria (the most frequent), with or without pernicious anemia;

2. Retained gastric antrum; 5. G cell hyperplasia; 7. Gastric outlet obstruction;

3. Renal insufficiency; 6. Massive small-bowel obstruction;

4. Conditions such as rheumatoid arthritis, vitiligo, diabetes mellitus, and pheochromocytoma.

A BAO/MAO ratio >0.6 is highly suggestive of ZES, but a ratio <0.6 does not exclude the diagnosis.

3. Gastrin provocative tests

a. Secretin injection test

An increase in gastrin of 200 pg within 15 min of secretin injection has a sensitivity and specificity of >90% for ZES.

b. Calcium infusion test study is less sensitive and specific than the secretin test.

4. Tumor Localization:

a. Endoscopic ultrasound (EUS) permits imaging of the pancreas with a high degree of resolution (<5 mm).

b. Somatostatin analogue 111In-pentreotide (Octreoscan) with sensitivity and specificity rate of >75%.

c. For metastases: Abdominal CT scan, MRI, or Octreoscan.

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