Peptic ulceration of the third part of the duodenum, associated with islet-cell Tumors of the pancreas

A short history of neuroendocrine tumours and their peptide hormones

The discovery of neuroendocrine tumours of the gastrointestinal tract and pancreas started in 1870, when Rudolf Heidenhain discovered the neuroendocrine cells, which can lead to the development of these tumours. Siegfried Oberndorfer was the first to introduce the term carcinoid in 1907. The pancreatic islet cells were first described in 1869 by Paul Langerhans. In 1924, Seale Harris was the first to describe endogenous hyperinsulinism/insulinoma. In 1942 William Becker and colleagues were the first to describe the glucagonoma syndrome. The first description of gastrinoma by Robert Zollinger and Edwin Ellison dates from 1955. The first description of the VIPoma syndrome by John Verner and Ashton Morrison dates from 1958. In 1977, the groups of Lars-Inge Larsson and Jens Rehfeld, and of Om Ganda reported the first cases of somatostatinoma. But only in 2013, Jens Rehfeld and colleagues described the CCK-oma syndrome. The most recently updated WHO classification for gastrointestinal neuroendocrine tumours dates from 2010.

Risk factors for esophagitis in extreme acid hypersecretors with and without Zollinger-Ellison syndrome

BACKGROUND & AIMS

Whereas severe duodenal ulcer is the hallmark of acid hypersecretion in Zollinger-Ellison syndrome (ZE) and similar states, the esophagus also is at high risk. We quantified the incidence of esophagitis and various risk factors that might contribute to it.

METHODS

Sixty-eight acid hypersecretors (basal acid output >15 mmol/h), 50 patients with ZE, and 18 patients without ZE with normal gastrin levels were studied by gastric analysis, serum gastrin levels, and endoscopy. In 44 of 68 patients, esophageal manometry was performed after the esophagus had healed.

RESULTS

Erosive esophagitis, grade 2 or worse, was found in 65%; an additional 15% had heartburn only, for a total reflux disease incidence of 80%. ZE accounted for 95% of severe esophagitis. Patients with and without esophagitis had the same high overnight fasting gastric residual volume and acidity, as well as basal and peak acid and pepsin outputs. However, patients with esophagitis had a lower median lower esophageal sphincter pressure (LESP) of 15.5 vs. 23 mm Hg in those without symptoms; the critical discriminator threshold was 16 mm Hg. Multivariate analysis further identified frequent vomiting and obesity as positive predictors of esophagitis, whereas Helicobacter pylori was a strong negative predictor (odds ratio, 0.16), possibly related to an elevated LESP in patients infected with H. pylori.

CONCLUSIONS

Erosive esophagitis is very common in acid hypersecretors. Identified risk factors that could promote abnormal esophageal exposure to the high acid and pepsin levels in our population of hypersecretors were vomiting, LESP < 16 mm Hg, and obesity, whereas H. pylori appeared to protect the esophagus not by reduced acid, but through an elevated LESP.

Gastrinoma before Zollinger and Ellison

BACKGROUND

The 1955 landmark publication by Zollinger and Ellison characterized the gastrinoma syndrome and presented a hypothesis for the pancreatic endocrine origin of the gastric hypersecretion and dramatic ulcer diathesis.

METHODS

A detailed review of the literature was conducted to ascertain the clinical and pathologic spectrum of gastrinoma reported prior to the definition of the Zollinger-Ellison syndrome.

RESULTS

In addition to the 2 patients presented by Zollinger and Ellison, 6 published reports of gastrinoma patients were referenced in their manuscript. An additional 6 patients were described by the 5 discussants of the presented paper. Thorough review of the literature has yielded 4, and possibly 6, additional cases of gastrinoma published between 1908 and 1952.

CONCLUSION

Despite experience with a sizeable number of gastrinoma patients, it was left to Zollinger and Ellison to define the association between the islet cell tumor, its peptide hormone, and the clinical manifestations of severe gastric hypersecretion. Their seminal contribution served as the defining moment for the field of gastrointestinal endocrinology.

Pathologic aspects of gastrinomas in patients with Zollinger-Ellison syndrome with and without multiple endocrine neoplasia type I

During the three decades since the recognition of the Zollinger-Ellison syndrome (ZES), major progress has been made in the diagnosis and treatment of this disease. However, the many failed operations in patients with ZES, the existence of primary lymph node gastrinomas, and the surgical approach of patients with ZES and multiple endocrine neoplasia type I (MEN-I) have remained controversial issues. In this review, our experience with the pathology of immunocytochemically identified gastrinomas in 44 patients with ZES is presented and related to the relevant literature. (1) Gastrinomas occur frequently in the duodenum (> 40%) and are commonly small (< 1 cm). They can therefore easily be missed at surgical exploration; lymph node metastases from such occult gastrinomas may be mistaken for primary tumors. (2) Most pancreatic gastrinomas reside in the head of the gland and have a diameter of 1 to 3 cm. (3) Gastrinomas associated with MEN-I are predominantly of duodenal origin and frequently multicentric; sporadic gastrinomas are single and more often pancreatic. Because MEN-I associated pancreatic tumors seldom contain gastrin, ZES in MEN-I patients is almost never cured by resection of the pancreatic tumors. (4) The metastatic potential of most small duodenal gastrinomas seems to be restricted to the regional lymph nodes.

Ulcerogenic tumor syndrome of the pancreas associated with a nongastrin acid secretagogue

Among 30 patients with islet cell neoplasms or hyperplasia who exhibited marked gastric acid hypersecretion and peptic ulceration and/or diarrhea, fasting plasma gastrin concentrations were less than 150 pg/ml in 11 patients, whereas the remaining 19 patients had hypergastrinemia. Plasma extracts from seven of these 11 patients were assayed for acid secretagogue activity in rats. All seven plasma extracts had secretagogue activity that was not found in the plasma extracts of ten patients with ordinary duodenal ulcer disease. Each of the tumor or pancreatic tissue extracts obtained from nine patients exhibited secretagogue activity in rats even though tissue gastrin content was 101.9 pmol (213.8 ng).g-1 or less. The secretagogue activity of the tumor extracts was confirmed in conscious gastric fistula dogs. The tumors' secretagogue activity, in contrast to gastrin, was destroyed by trypsin. It was eluted between porcine motilin and human gastrin I from a Sephadex G-50 (Pharmacia LKB Biotechnology, Inc., Piscataway, NJ) superfine column and was not retained by CM-cellulose, at pH 8.5. Its retention time during reverse phase HPLC on a C18 column also differed from those of G17 and G34. Thus, this secretagogue activity appeared mediated by a small, acidic peptide with a molecular size of about 2000 to 3000 daltons. The present study indicates that plasma and tumor extracts of these 11 patients contain a gastric acid secretagogue activity mediated by a nongastrin peptide. We suggest that what may be a distinct clinical entity associated with endocrine neoplasms of the pancreas should be considered in the face of excessive acid hypersecretion without fasting hypergastrinemia.

Gastrinoma. New medical and surgical approaches

The clinical presentation of gastrinoma has changed since the original description by Zollinger and Ellison in 1955. Tumors currently found are smaller, extrapancreatic or extraintestinal in location, and frequently occult within lymph nodes. The incidence of hepatic metastases on initial presentation has decreased. In addition, the clinical course of patients with tumor in lymph nodes is benign, suggesting that more patients than were previously thought are now candidates for cure. Improved knowledge of the anatomic location of gastrinomas has enhanced our ability to find and remove them at laparotomy. As a result of these factors, more patients are being cured than ever before, and in the future, cure rate may be even higher. On the basis of these recent advances, the optimal treatment of gastrinoma is surgical excision for cure.

Conservative surgery in Zollinger-Ellison syndrome: report of a case with an eight-year follow-up

The patient described here, with malignant non-beta islet cell tumor of the head of the pancreas, was treated by resection of the tumor and metastases. Additional pathology of perforated duodenal ulcer and pyloric stenosis required vagotomy and pyloroplasty. The maintenance of normal gastrin levels after the operation indicates a good prognosis. We believe that the low-risk Zollinger-Ellison patient should be treated surgically and the tumor removed. When no tumor can be detected, parietal cell vagotomy should be performed to assist the pharmacological control of the gastric acid hypersecretion. Extensive surgery, such as total gastrectomy, is no longer the treatment of choice and is reserved for the so-called "cimetidine failure."

Two types of Zollinger-Ellison syndrome: immunofluorescent, cytochemical and ultrastructural studies of the antral and pancreatic gastrin cells in different clinical states

In this survey the antral, pancreatic and, where present, the neoplastic gastrin cells, were studied in eight cases of the Zollinger-Ellison syndrome. The antral G cells alone were studied in one case of Z-E syndrome, seven cases of simple duodenal ulcer, and five cases of pernicious anaemia. The Z-E cases were divided into two numerically equal groups. The first group had ;short' histories, high serum gastrin levels, and profound antral G cell hyperplasia. The second group had ;long' histories, relatively lower serum gastrin levels, normal antral G cells, and either pancreatic D cell hyperplasia or gastrinoma. Antral G cell hyperplasia, with maximal gastrin storage and normal serum gastrin levels, was found in the duodenal ulcer cases. Antral G cell hyperplasia with minimal storage and high serum gastrin levels was observed in the cases of pernicious anaemia. On the basis of our findings we propose that there exist at least two distinct types (or perhaps stages) of the Z-E syndrome. Suggestions for their pathogenesis are offered.

The Zollinger-Ellison syndrome in a child

The Zollinger-Ellison syndrome was encountered in a boy aged 11 years who presented with a bulbar duodenal ulcer causing intractable pain and bleeding. The diagnosis was made by finding an overnight fasting gastric secretion of 1,300 ml containing 134 m-equiv/HCl, and little change of secretion after maximal histamine stimulus. A circumscribed non-beta islet cell pancreatic tumour was excised, with antrectomy. Postoperative acid secretion was normal and the boy was well after being followed up for 15 months. The diagnosis and management are discussed, as the view that total gastrectomy must be performed in all cases of the Zollinger-Ellison syndrome is questioned.

Carcinoid-islet cell tumors of the duodenum

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Islet tumours of the pancreas with intractable diarrhoea

This paper reports the association between severe, prolonged, watery diarrhoea and islet cell tumours of the pancreas. There appear to be significant differences between patients with these symptoms and those with the classical Zollinger-Ellison syndrome.