April 2019 - Question 2

Critique:

Factors raising suspicion for Zollinger-Ellison syndrome include recurrent peptic ulcer disease, multiple ulcers, post-bulbar ulcer, non-H. pylori/non-NSAID-related duodenal ulcer, diarrhea, erosive esophagitis, and family or personal history of multiple endocrine neoplasia type 1. The patient in this question presents with duodenal ulcer without H. pylori or NSAID use, erosive esophagitis, and diarrhea, which raises suspicion for hypergastrinemia.   
His laboratory evaluation also showed hypercalcemia, which may be due to hyperparathyroidism, a condition related to MEN I. The initial test to obtain when gastrinoma is suspected includes a fasting serum gastrin level. In follow-up of gastrin elevations, a gastric pH assessment should be performed and, depending on these results, a secretin stimulation test may be useful. Routine repeat upper endoscopy is not indicated after hemostasis of duodenal ulcer bleeding.  
A restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL has been shown to result in improved clinical outcome compared to a liberal transfusion strategy. While sucralfate may help the healing of duodenal ulcers, it is not the first-line therapy for long-term secondary prevention.  
 
References 
1. Roy PK, Venzon DJ, Shojamanesh H, et al. Zollinger-Ellison syndrome. Clinical presentation in 261 patients. Medicine (Baltimore) 2000;79:379. 
2. Murugesan SV, Varro A, Pritchard DM. Review article: Strategies to determine whether hypergastrinaemia is due to Zollinger-Ellison syndrome rather than a more common benign cause. Aliment Pharmacol Ther 2009;29:1055-68. 
3. Villaneuva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21.

Critique:

Factors raising suspicion for Zollinger-Ellison syndrome include recurrent peptic ulcer disease, multiple ulcers, post-bulbar ulcer, non-H. pylori/non-NSAID-related duodenal ulcer, diarrhea, erosive esophagitis, and family or personal history of multiple endocrine neoplasia type 1. The patient in this question presents with duodenal ulcer without H. pylori or NSAID use, erosive esophagitis, and diarrhea, which raises suspicion for hypergastrinemia.   
His laboratory evaluation also showed hypercalcemia, which may be due to hyperparathyroidism, a condition related to MEN I. The initial test to obtain when gastrinoma is suspected includes a fasting serum gastrin level. In follow-up of gastrin elevations, a gastric pH assessment should be performed and, depending on these results, a secretin stimulation test may be useful. Routine repeat upper endoscopy is not indicated after hemostasis of duodenal ulcer bleeding.  
A restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL has been shown to result in improved clinical outcome compared to a liberal transfusion strategy. While sucralfate may help the healing of duodenal ulcers, it is not the first-line therapy for long-term secondary prevention.  
 
References 
1. Roy PK, Venzon DJ, Shojamanesh H, et al. Zollinger-Ellison syndrome. Clinical presentation in 261 patients. Medicine (Baltimore) 2000;79:379. 
2. Murugesan SV, Varro A, Pritchard DM. Review article: Strategies to determine whether hypergastrinaemia is due to Zollinger-Ellison syndrome rather than a more common benign cause. Aliment Pharmacol Ther 2009;29:1055-68. 
3. Villaneuva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21.

Critique:

Factors raising suspicion for Zollinger-Ellison syndrome include recurrent peptic ulcer disease, multiple ulcers, post-bulbar ulcer, non-H. pylori/non-NSAID-related duodenal ulcer, diarrhea, erosive esophagitis, and family or personal history of multiple endocrine neoplasia type 1. The patient in this question presents with duodenal ulcer without H. pylori or NSAID use, erosive esophagitis, and diarrhea, which raises suspicion for hypergastrinemia.   
His laboratory evaluation also showed hypercalcemia, which may be due to hyperparathyroidism, a condition related to MEN I. The initial test to obtain when gastrinoma is suspected includes a fasting serum gastrin level. In follow-up of gastrin elevations, a gastric pH assessment should be performed and, depending on these results, a secretin stimulation test may be useful. Routine repeat upper endoscopy is not indicated after hemostasis of duodenal ulcer bleeding.  
A restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL has been shown to result in improved clinical outcome compared to a liberal transfusion strategy. While sucralfate may help the healing of duodenal ulcers, it is not the first-line therapy for long-term secondary prevention.  
 
References 
1. Roy PK, Venzon DJ, Shojamanesh H, et al. Zollinger-Ellison syndrome. Clinical presentation in 261 patients. Medicine (Baltimore) 2000;79:379. 
2. Murugesan SV, Varro A, Pritchard DM. Review article: Strategies to determine whether hypergastrinaemia is due to Zollinger-Ellison syndrome rather than a more common benign cause. Aliment Pharmacol Ther 2009;29:1055-68. 
3. Villaneuva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21.