Antral-gastrin-cell hyperplasia in peptic-ulcer disease

Social and natural environmental factors cause the birth-cohort phenomenon of peptic ulcers by superposition mechanism

The widely believed Helicobacter pylori infection has never explained the birth-cohort phenomenonof peptic ulcers. Although numerous studies have observed that environmental factors are associated with peptic ulcers, their role in the disease has yet to be identified. A new etiological theory proposed that environmental factors cause peptic ulcers via inducing psychological stress. Starting from this etiology, an integration of the mortality rates caused by social and natural environmental factors reproduced a representative fluctuation curve in the birth-cohort phenomenon, where a causal role of environmental factors in peptic ulcers was hidden. The reproduced fluctuation curve revealed that multiple environmental factors caused the birth-cohort phenomenon by Superposition Mechanism, and the causal role of each individual environmental factor surfaced if the fluctuation curves in the birth-cohort phenomenon were properly differentiated. A full understanding of the birth-cohort phenomenon highlights the importance of environmental management in improving clinical outcomes, and suggests that the Superposition Mechanism is an indispensable methodological concept for life science and medicine.

Diagnosis and differential diagnosis of hypergastrinemia

The most frequent conditions of hypergastrinemia in man are the Zollinger-Ellison syndrome with autonomous gastrin hypersecretion by the tumour cell and reactive hypergastrinemia in type A autoimmune chronic atrophic gastritis with achlorhydria causing unrestrained gastrin release from the gastrin-producing antral G-cells. Both entities differ with respect to the pH in the gastric fluid, which is < 2 in patients with Zollinger-Ellison syndrome and neutral in type A gastritis. Other conditions with moderate hypergastrinemia as treatment with proton pump inhibitors, gastric outlet obstruction, previous vagotomy, chronic renal failure or short bowel syndrome are of minor clinical importance.

Development of an inveterate gastroduodenal ulcer caused by antral G-cell hyperplasia of the stomach (pseudo-Zollinger-Ellison Syndrome): report of a case

We describe herein the case of a 54-year-old Japanese woman in whom an inveterate peptic ulcer developed in association with pseudo-Zollinger-Ellison Syndrome (pseudo-ZES). The patient presented with weight loss and abdominal distension caused by antral and duodenal stenosis due to an inveterate peptic ulcer. Her serum gastrin level was very high; however, no evidence of a gastrinoma or carcinoid tumor was detected by preoperative examinations or surgery. A total gastrectomy and double-tract reconstruction was performed, and pathological examination revealed a gastric ulcer (UL-IV) with no histopathological evidence of a neoplasm. Immunohistochemical staining showed an obvious increase in the number of endocrine cells that were positive for chromogranin A, and marked G-cell hyperplasia was observed in the antral mucosa. Furthermore, the number of enterochromaffin-like cells was remarkably high. From the results of the immunohistochemical examination, the patient was diagnosed as having hypergastrinemia due to antral G-cell hyperplasia. Postoperatively, the patient's serum gastrin level fell rapidly to within the normal range, her nutritional status improved, and her weight increased by about 10 kg within 1 year.

Is antral gastrin important in the resistance of duodenal ulcers to H2 receptor antagonists or in recurrent ulceration after highly selective vagotomy?

Basal serum gastrin, integrated gastrin response to a meal, and integrated gastrin response to insulin induced hypoglycaemia were measured in 60 patients with duodenal ulcer before and after elective highly selective vagotomy to determine whether antral gastrin has a role in resistance to H2 receptor antagonist treatment which the patients had received before surgery or in the development of recurrent ulceration after vagotomy. The basal gastrin, integrated gastrin response to a meal, and the integrated gastrin response to insulin were similar in patients whose ulcers healed after H2 receptor agonist treatment or were refractory to at least three months of this treatment. The same parameters measured before or after highly selective vagotomy were similar in patients who eventually developed recurrent ulceration compared with those who did not. As expected the basal and meal stimulated (but not insulin stimulated) serum gastrin values increased after highly selective vagotomy. Ulcer patients with particularly high gastrin values (whether basal or stimulated) were not more resistant to H2 receptor antagonist treatment or prone to develop ulcer recurrence after highly selective vagotomy. This study suggests that antral gastrin is not important in 'resistance' of duodenal ulceration either to H2 receptor antagonist treatment or to highly selective vagotomy.

Prospective study of the standard meal provocative test in Zollinger-Ellison syndrome

PURPOSE

The purpose of this work was to evaluate the proposed usefulness of a standard meal-stimulated gastrin provocative test in: (1) distinguishing Zollinger-Ellison syndrome (ZES) from antral syndromes; (2) localizing duodenal gastrinomas; or (3) suggesting that patients with multiple endocrine neoplasia type I (MEN-I) may have an increased incidence of antral syndromes.

PATIENTS AND METHODS

Seventy-four consecutive patients with ZES referred to the National Institutes of Health were studied prospectively. The extent and location of gastrinomas, acid secretory studies, and the presence or absence of MEN-I were determined and correlated with the results of the gastrin response to standard meal provocative testing.

RESULTS

For patients with fasting serum gastrin levels less than 1,000 pg/mL (n = 43), only 44% had a less than 50% increase over the pre-meal value, which is reported to be the typical response in ZES, and 40% had a 50% to 99% increase. Furthermore 16% had a 100% or greater increase, 9% a 150% or greater increase, and 5% a 200% or greater increase, which overlaps with values reported to be characteristic of 98%, 92%, and 46% of patients with antral syndromes. Results did not differ for patients with or without MEN-I, depend on the extent of the gastrinoma (duodenal versus pancreatic gastrinomas), the presence of previous gastric surgery or type of gastric surgery, or for patients with fasting serum gastrin concentrations greater than or equal to 1,000 pg/mL or less than 1,000 pg/mL. studies of four patients before and after resection of the gastrinoma, who prior to surgery had a greater than 100% increase in gastrin secretion after the meal, demonstrated that all patients had a less than 100% increase postoperatively even though no gastric resection was done.

CONCLUSIONS

Approximately half of the patients with ZES have a greater than 50% increase in serum gastrin concentration following a standard test meal and one fifth have a 100% or greater increase. Therefore, they cannot be distinguished on this basis from patients with antral syndromes. The increased serum gastrin level after the meal in these patients with ZES appears to be due to the gastrinoma. Furthermore, the current study provides no evidence for the proposals that antral syndromes are more common in patients with MEN-I, that gastric surgery affects the meal response in patients with gastrinomas, or that the meal test is useful in localizing duodenal gastrinomas.

Gastrin and somatostatin cells in dyspeptic patients with and without duodenal ulcer: a quantitative study based on multiple biopsy specimens

The numbers of immunoreactive gastrin and somatostatin cells in gastric and duodenal mucosal biopsy specimens from dyspeptic patients with duodenal ulcers and dyspeptic controls without ulcers were calculated using a morphometric method. The levels of gastrin and somatostatin in the tissue were also measured by the radioimmunoassay. The results showed no significant difference in the number of G cells and the level of gastrin in the tissue between the ulcer and non-ulcer groups. However, the number of D cells and the level of somatostatin in the tissue in ulcer patients were remarkably reduced in comparison with those in non-ulcer patients (P less than 0.01 and P less than 0.05, respectively). The G:D cells and gastrin:somatostatin ratios in ulcer patients were much higher than those in the non-ulcer control group. It is considered that the reduction of D cells and the relative lack of somatostatin in duodenal ulcer patients might have a role in the mechanism of the duodenal ulceration.

Pseudo-Zollinger--Ellison syndrome in a child presenting with anemia

Pseudo-Zollinger--Ellison syndrome appears to very rarely afflict young children. Hypergastrinemia, regardless of the etiology, presents with signs and symptoms of nonhealing or multiple gastric or duodenal ulcers, or both. We present a 7-yr-old boy with fasting hypergastrinemia (serum gastrin 200-500 pg/ml) who had mild to moderate iron deficiency anemia, but was asymptomatic. Stool guaiac was positive and gastric acid secretion was almost 40-fold above normal. Endoscopy showed multiple small gastric fundal ulcerations and severe gastritis. Workup for Zollinger--Ellison syndrome was negative. Changes in serum gastrin levels after secretin injection and after ingestion of a protein meal were compatible with those noted in adults with pseudo-Zollinger--Ellison syndrome. This child may be the first case of pseudo-Zollinger--Ellison syndrome under the age of 17 yr.

Antral gastrin-producing G-cells and somatostatin-producing D-cells in peptic ulcer

The number of G cells and D cells per area unit and the G cell/D cell ratio was studied in control subjects and patients with duodenal or gastric ulcer. A great inter-individual variation in the population density of both types of cells was observed in the three groups studied. G cell density was significantly decreased in both duodenal and gastric ulcer patients, when compared with controls; whereas no difference in G cell density was seen between duodenal ulcer patients and gastric ulcer patients. However, D cell density was significantly decreased in duodenal ulcer patients when compared with control subjects and gastric ulcer patients. In this latter group, D cell density was also lower than in control subjects. A significant positive linear correlation between G cell number and D cell number was found in the three groups studied. The G cell/D cell ratio was significantly increased in duodenal and gastric ulcer patients when compared with controls. This was mainly due to a decrease in D cell numbers. It is concluded that a local deficit in antral D cells in patients with peptic ulcer may favor the pathogenesis of ulcer disease.

Gastrinoma

Although there are multiple etiologies of clinical hypergastrinemia, the most important cause is gastrinoma [Zollinger-Ellison (ZE) syndrome]. The most significant advance in the management of patients with the ZE syndrome has been the development of the ability to establish firmly the correct preoperative diagnosis by radioimmunoassay. We believe that all patients who have the ZE syndrome should undergo operation for two reasons: to identify and resect all tumor and because in patients in whom no tumor is found or in whom all tumor cannot be resected, the most reliable relief of hypersecretory symptoms for the life of the patient can be achieved by total gastrectomy.

Decision analysis in evaluation of hypergastrinemia

Hypergastrinemia and gastric acid hypersecretion are the principal laboratory features of Zollinger-Ellison syndrome. Decision and cost-effectiveness analyses were employed in the present study to compare and contrast the diagnostic strategies of initial gastric analysis followed by secretin infusion test versus secretin infusion test alone in the evaluation of hypergastrinemia in patients suspected of having gastrinoma. The results of this study showed that 59 percent of patients with elevated serum gastrin values were either hypochlorhydric or achlorhydric. Application of decision analysis to either diagnostic strategy demonstrated that gastric analysis followed by secretin infusion test, if indicated, was superior in expected value than secretin infusion test alone. Likewise, in this group of patients, performance of gastric analysis in the outpatient setting prior to secretin infusion testing was financially more advantageous than performance of secretin infusion testing alone. These results also demonstrate the importance of performing gastric analysis prior to anticipated hospitalization for evaluation of suspected gastrinoma. Such testing would obviate unnecessary hospitalization and medical costs.

A histopathological study of diffuse hyperplasia of gastric argyrophil cells

The present study includes a histopathological and immunohistochemical study of 4 cases of diffuse hyperplasia of gastric argyrophil cells. The mode of proliferation of these cells and the production of hormone by these cells have been documented. The distribution of microacinar nests composed of argyrophil cells was thought to be related to chronic gastritis in which there are atrophy of mucosa and intestinal metaplasia. In the case in which these nests were found only in the corpus ventriculi, there was intestinal metaplasia throughout the stomach. On the other hand, in the case in which these nests appeared only in the pyloric area, atrophy of the mucosa with mild intestinal metaplasia was observed only in the pyloric area. The microacinar nests composed of argyrophil cells were distributed in the deep mucosa at the basal portion of the glands in the area with intestinal metaplasia. Serial sections revealed a sprout composed of argyrophil cells budding from the gland with intestinal metaplastic changes. The sprout buds out from the growth zone of glands with intestinal metaplasia and then becomes isolated and gives rise to reactive hyperplasia. The peptide hormone contained in these cells differs according to the mucosal environments. Cells containing gastrin were observed in the pyloric area, but not in the corpus ventriculi where there was marked intestinal metaplasia. The cells in this area were assumed to contain other hormones.

The prevalence of gastrinomas in recurrent peptic ulceration

The prevalence of gastrinomas and the Zollinger-Ellison syndrome is unknown. In order to examine a high risk group of patients, basal and secretin-provoked plasma gastrin levels were determined in 50 consecutive patients, predominantly from the west of Scotland. All had endoscopically proven recurrent peptic ulceration following duodenal ulcer surgery. This resulted in three cases strongly suspected of having a gastrinoma. Further investigations including exploratory laparotomy were unable to demonstrate a gastrinoma in two, but the evidence suggested an occult tumour in one. In this remaining unoperated patient, the serum gastrin returned to normal. The reference range for both basal and secretin stimulated gastrin response and percentage change has been determined in normal control subjects (n = 10) and in primary ulcer patients (n = 20). It is concluded that in this study, gastrinomas had a less than 2 per cent prevalence in patients presenting with recurrent peptic ulceration. As the diagnosis of a gastrinoma changes the surgical approach, conducting screening tests still seems warranted.

Gastrin release in fistula dogs with solid compared to nutrient and nonnutrient liquid meals

Using conscious gastric fistula dogs, gastrin release stimulated by a 360-g meat-based solid meal was compared to that stimulated by two isocaloric (1 kcal/g), hypertonic (approximately 700 mosm/kg) nutrient liquids (Sustacal and Vivonex) and by two nonnutrient, hypotonic (60 mosm/kg) liquids (mannitol and coffee). Serum gastrin levels were measured at 15- to 30-min intervals over 120 min. Without a meal, serum gastrin levels remained stable. Effectiveness in stimulating gastrin release was coffee = mannitol less than Sustacal = Vivonex less than solid food; 2-hr integrated gastrin responses were 1.2, 2.6, 4.3, 5.6, and 12.2 ng/ml/min, respectively. The greater gastrin responses produced by nutrient liquids and meat meals could be explained by slower emptying and delayed acidification of gastric contents. We conclude that solid meals are preferable to liquid meals in studies of antral gastrin release.

The early diagnosis of gastrinoma

Despite the increasing awareness of gastrinoma and its lethal peptic ulcer sequelae, the diagnosis is often initially missed or made as a terminal event. The authors screened all patients with peptic ulcer symptoms serious enough to warrant hospital admission or those associated with diarrhea, nephrolithiasis, hypercalcemia, or pituitary abnormality. In a one-year period (1979-1980) nine (of 14 suspected) new gastrinoma patients were identified using a sensitive and specific gastrin radioimmunoassay in combination with provocative tests including IV secretin, calcium, and food. Conventional upper GI series, CAT scan, arteriography, and endoscopy provided no additional information other than to confirm the presence of ulcer disease. Basal plasma gastrin levels were more than 200 pmol L-1 in only three of the nine (normal fasting plasma gastrin levels are less than 25 pmol L-1). Three patients presented with acute ulcer perforation, and the diagnosis of gastrinoma was suspected because of multiple ulcers and pancreatic masses. In three other patients, previous duodenal ulcer surgery had failed. One patient with dyspepsia, high basal plasma gastrin, negative secretin and calcium infusion studies, and a positive meal test was diagnosed as having G-cell hyperplasia; this was confirmed by biopsy and antral gastrin extraction. Antrectomy alone resulted in cure. In all patients tested, a positive calcium infusion or secretin bolus (greater than 100% rise over basal) strongly suggested the diagnosis of gastrinoma, which was confirmed at surgery. In the acute perforations, initial management with omental patch and cimetidine therapy allowed survival of two patients, while emergency total gastrectomy in the third resulted in death due to esophagojejunal leak. Elective patients were treated with cimetidine initially for at least two weeks before total gastrectomy. In this group there were no operative mortalities, and postoperative morbidity was minimal. This series illustrates three important points: (1) careful screening of an ulcer population using gastrin radioimmunoassay and provocative tests has enabled a high yield of gastrinomas while conventional investigations are of minimal values; (2) a high index of suspicion in appropriate cases is necessary; and (3) total gastrectomy performed under elective circumstances is safe and allows the patients to resume a normal and healthy life without the sequelae of aggressive peptic ulceration or daily drug administration.

Mucosal biopsy of the esophagus, stomach, and proximal duodenum

The past decade has occasioned the development and extensive use of flexible endoscopes for visualization of large areas of the alimentary tract. Numerous small grasp biopsies are now performed to determine the diagnosis and course of a large variety of inflammatory and neoplastic disorders. In this review, the authors have concentrated on the uses and interpretation of endoscopy and biopsy of the upper alimentary tract including the esophagus, stomach, and proximal duodenum. They have also commented on the limitations of endoscopic biopsy with respect to its size, superficial nature, and imperfect orientation in the evaluation of some disorders.

Pseudo-Zollinger-Ellison syndrome: hypergastrinemia, hyperchlorhydria without tumor

The purpose of the investigation was to detect ulcer patients having nontumorous hypergastrinemic hyperchlorhydria and to diagnostically differentiate this pseudo-Zollinger-Ellison syndrome from neurogenic duodenal ulcer disease and pancreatic gastrinomas. Nine patients having clinical, radiologic and humoral findings simulating the Zollinger-Ellison syndrome or severe duodenal ulcer disease were studied by physiologic provocative testing. The patients, not having pancreaticoduodenal gastrinomas, had an antral mucosal source of their moderate hypergastrinemia even after vagotomy with drainage, which was eliminated in eight patients treated by surgical antrectomy, resulting in normal serum gastrin concentrations. The pseudo-Zollinger-Ellison syndrome is, thus, characterized physiologically by an exaggerated gastrin response to meals, no response to secretin stimulation and pathologically by hyperfunctioning hyperplastic G cells of the antrum. The clinical, physiologic, pathologic and surgical features were integrated for accurate diagnosis and treatment.

Clinical significance of glucagon provocation test in the diagnosis of hypergastrinemia

Glucagon provocation test was performed in the patients with hypergastrinemia and hyperchlorhydria to investigate its diagnostic value. A paradoxical response of plasma gastrin level in the patients with the Zollinger-Ellison syndrome and a marked decrease of plasma gastrin level in the patients with gastric ulcer, duodenal ulcer, excluded gastric antrum, multiple endocrine adenomatosis, pernicious anemia and chronic renal failure were demonstrated by glucagon infusion. Glucagon provocation test, therefore, was considered to be of great value in the diagnosis of the Zollinger-Ellison syndrome, particularly, in the case of an excluded gastric antrum in which secretin provocation test caused the false positive result because of a marked increase of pancreatic secretion. Glucagon provocation test in combination with secretin provocation test, therefore, is at present the most preferable diagnostic procedure for detecting the Zollinger-Ellison syndrome.U

Quantitative studies of the gastrin-producing cells of the human antrum. A methodological study

The antral gastrin-producing cells (G-cells) have been identified by the indirect immunoperoxidase technique in two antrum preparations removed due to a recurrent duodenal and gastric ulcer. Morphometric principles were applied to the G-cells with determination of their volume density, numerical density, and mean cell volume. The study showed that within-observer variation, between-observer variation and within-patient variation were negligible, provided at least 200 G-cells were counted. A biopsy material can be used, as well as larger tissue blocks, when this minimum sample size is respected. A method for estimating the total G-cell population and the total G-cell volume in the antrum was developed. In the antrum removed due to a gastric ulcer the number of G-cells was 190 x 10(6) and their total volume 176 mm3.

Long-term results of selective vagotomy plus pyloroplasty. 12 to 17 year follow-up

Among an initial series of 103 patients with selective vagotomy plus pyloroplasty for duodenal ulcer, 9 patients died of causes unrelated to ulcer and 7 were lost to follow-up without signs or symptoms of ulcer 8 to 15 years after operation; the remaining 87 patients were followed up for 12 to 17 years. Insulin testing revealed only one inadequate vagotomy in a patient who had a recurrence in the short term. Insulin tests were negative in 61 and negative or adequate in 6 other patients. Complete vagotomy reduced basal secretion effectively in the great majority of patients but not in a small minority. Three patients had antral hyperfunction with persistent hypersecretion despite complete vagotomy as indicated by two negative insulin tests in each patient. Inexplicably, only one of these patients had a stomal ulcer recurrence. Long-term follow-up revealed the development of gastric ulcer in one patient wit stasis from a pyloroplasty stenosed by angulation from adhesions. Three other patients, one with ulcer and two with hemorrhagic gastritis, developed gastric ulceration in the long term despite low acid output and negative insulin tests. Biliary reflux was demonstrated in two of these three patients and was probably the cause of gastric ulcer in the third. Pre- and postoperative cholecystograms in 66 patients showed the formation of gallstones in 4 patients after vagotomy. Another patient who did not undergo cholecystography developed acute cholecystitis from stone. This rate of gallstone formation was the normal expected rate and was not increased as in some series of total vagotomy. Dumping with and without associated diarrhea was the most frequent and troublesome sequela. Postvagotomy diarrhea did not occur. To prevent dumping, and also to decrease acid secretion more effectively, pyloroplasty was abandoned in favor of Maki's pyloruspreserving antrectomy to complement selective vagotomy in 1968.

G-cell population and serum gastrin response to cimetidine-OXO test meal in relation to histopathological alterations in resected stomachs from patients with peptic ulcer disease

The relationship between histopathological alterations and G-cell population in the stomach was studied in l4 resected stomachs from patients with chronic peptic ulcer disease (6 with duodenal ulcer and 8 with gastric ulcer). G-cells were identified by indirect immunoperoxidase method. When atrophy was graded three steps (0, 1, 2), the average grade of DU and GU was 0.23 and 0.89, respectively. There was a significant correlation (r=0.871, p less than 0.005) between atropic grade and G-cell population in each stomach. The mean occupation rate with intestinal metaplasia was 0.9% in DU and 35.8% in GU. There was no correlation between total pyloric area and G-cell population, however residual pyloric area excluding intestinal metaplasia correlated significantly with G-cell population (r=0.557, p less than 0.05). There was a significant difference in the mean G-cell population which were 26.5 millions in DU and 8.9 millions in GU. The mean integrated gastrin response to Cimetidine-OXO test meal were 559+/-236 pg/ml in DU and 216+/-124 pg/ml in GU, and there was significant correlation (r=0.889, p less than 0.005) between G-cell population and integrated gastrin response. The average age of both groups, however, was 27.7 in DU and 52.8 in GU, so that these differences of G-cell population and functional G-cell mass in both groups might originate in the histopathological alterations accompanying with the aging.

Antral gastrin cell hyperplasia in patients with peptic ulcer

The total number of gastrin (G) cells in the stomach was determined by using a histologic counting method and planimetry in ulcerous and nonulcerous patients. The preoperative basal and postprandial serum gastrin values and the gastrin cell mass in the gastrectomy specimen could be compared in 16 surgical patients. There was a significant correlation between the integrated gastrin response to feeding and the total gastrin cell number in the stomach. No correlation was found between the basal serum gastrin level and the total gastrin cell count. A total gastrin cell number higher than 50 million was found in the stomach of three duodenal ulcer patients with preoperative postprandial hypergastrinemia as well as in one patient with normal serum gastrin values. Gastrin cell counts between 6 and 42 million were found in control stomachs and in patients with gastric ulcer. Preoperative feeding tests could be useful to select patients with an elevated antral G cell number.

Endocrinology of duodenal ulcer

Several gastrointestinal peptides with proven or suggested endocrine or paracrine functions influence gastric acid secretion, gastrointestinal motility, and mucosal blood flow. Increased or decreased release of such factors could participate in the pathogenesis of duodenal ulcer disease by inducing increased gastric acid concentration in the duodenal bulb. To date, increased stimulation of parietal cells by gastrin has been demonstrated only in patients with gastrinoma, G-cell hyperplasia, gastric outlet obstruction, hyperparathyroidism, excluded antrum, and short bowel syndrome, but not in the usual duodenal ulcer disease. Also, a defective inhibition of parietal cell function by endocrine or paracrine factors, such as gastric inhibitory polypeptide, secretin, somatostatin and vasoactive intestinal polypeptide, seems not to exist in patients with duodenal ulcer disease. However, as long as the physiology of gastrointestinal peptides in gastric secretion and motility is not understood, a possible role of these factors in the pathogenesis of simple duodenal ulcer disease cannot be excluded.

Gastrin cell populations after highly selective vagotomy in the dog

Highly selective vagotomy was performed on five dogs. Postoperatively, gastrin cell (G cell) hyperplasia occurred in all dogs. Mean preoperative G cell numbers increased from 350 to 530/cm mucosal length (p less than 0.02). Antral tissue gastrin also increased by 100 per cent (6.7 x 10(6) to 13.7 x 10(6) pg/gm tissue, p less than 0.05). Basal and stimulated serum gastrin were unchanged following highly selective vagotomy. The cause for G cell hyperplasia is not clear, but is probably multifactorial.

Hypergastrinemia of antral origin in duodenal ulcer

A case of recurrent duodenal ulcer, basal gastric hypersection, and hypergastrinemia of antral origin is presented. The diagnosis was suggested preoperatively by stimulation tests with secretin and food. Billroth II antrectomy led to normalization of serum gastrin within half an hour. The gastrin content of the antral mucosa was not increased, neither was antral G-cell hyperplasia demonstrable. Postoperatively the basal gastric acid output and fasting serum gastrin levels were normal, without a postprandial increase in serum gastrin concentrations. The case does not support the existence of a specific disease called antral G-cell hyperplasia.

The Zollinger-Ellison syndrome--23 years later

The effects of recent diagnostic and therapeutic advances were assessed in 65 patients with the Zollinger-Ellison syndrome (ZES). Twenty-seven patients seen between 1955 and 1970 were compared with 38 patients seen between 1971 and 1977. The earlier patients had a higher incidence of virulent ulcer disease (56% vs. 24%), other endocrinopathies (48% vs. 13%), and malignant gastrinoma (44% vs. 25%). Earlier diagnosis is the result of liberal use of serum gastrin measurements and provocative tests for gastrin release (calcium and secretin), and an increased awareness of this syndrome. Because their basal gastrin values were in a range that overlapped ordinary ulcer disease, 47% of patients encountered in recent years required provocative testing with secretin for diagnosis. If the gastrin concentration falls to normal following resection of a gastrinoma, the tumor has probably been completely removed. In our patients, gastrin measurements after total gastrectomy had no prognostic significance in regards to clinical progression or regression of the neoplasm. Of 12 patients treated with cimetidine, nine experienced symptomatic improvement, and three did not. Resection of the gastrinoma should be attempted if the lesion is solitary and located in the body or tail of the pancreas, or if it is an isolated duodenal lesion. Otherwise, total gastrectomy remains the treatment of choice. In 38 patients, total gastrectomy with Roux-en-Y esophagojejunostomy was followed by 97% survival and minimal difficulties with nutrition or dumping.

Management of recurrent peptic ulceration

A series of 117 consecutive patients having operations for recurrent peptic ulcer is reported. There were no initial deaths but 9 patients developed further recurrent ulcer and 2 of 8 who had a third operation died, giving an overall patient mortality of 1.7 per cent. A further 6 patients underwent a third operation to correct bile vomiting or dumping, with no deaths.

The mean time of onset of symptoms of recurrent ulcer was 1.9 years after proximal gastric vagotomy, 3.2 years after vagotomy and drainage, 3.3 years after gastrectomy and 12.6 years after gastrojejunostomy.

One hundred and four patients were followed for more than 1 year (mean 5.2 years) and the result was good in 77 per cent. After a third operation the proportion of good results was improved to 88 per cent.

Second recurrence occurred in 1 of 43 patients after revagotomy and gastrectomy, in 2 of 28 after resection alone and in 6 of 33 after vagotomy or revagotomy alone (P &lt;0.05). When the patients whose primary operation included neither vagotomy nor gastric resection were excluded, there was a similar trend but the differences were not significant. It is suggested that gastric resection or re-resection should be combined with vagotomy or revagotomy whether the primary operation has been gastrectomy, vagotomy with or without drainage or gastrojejunostomy alone.

Prevalence of endocrine abnormalities in patients with the Zollinger-Ellison syndrome and in their families

To evalute the frequency of associated and hereditary endocrinopathies in the Zollinger-Ellison syndrome, 10 patients with the syndrome were studied. In seven of them, coexisting endocrine disease was found. In six, the Zollinger-Ellison syndrome was probably a feature of multiple endocrine adenomatosis type I, whereas Cushing's syndrome in the remaining patient may have been caused by the production of an ACTH-like substance by a mixed pancreatic tumor. A total of 109 family members, including all living first degree relatives over 15 years of age, were screened for endocrine abnormalities. All six patients with evidence of multiple endocrine adenomatosis type I had relatives with endocrinopathies. In the families of the four other patients with the Zollinger-Ellison syndrome, no endocrine abnormalities were found. During this study four new cases of pituitary tumor, 17 of hyperparathyroidism, seven of the Zollinger-Ellison syndrome and one of insulinoma were detected. Although most of the disorders were asymptomatic, this clearly indicates that patients suffering from Zollinger-Ellison syndrome and also their families should undergo detailed endocrine studies.

Antral gastrin concentration in upper-gastrointestinal disease

Antral gastrin concentration (AGC) was measured in prepyloric mucosa specimens obtained by forceps biopsy during endoscopic examination of 174 clinic and hospital patients. AGC in 32 patients who had normal endoscopic findings, the control group, varied widely from 2 to 38.6 ng gastrin/mg tissue. The mean AGC of the control patients was 14.2 +/- 1.4 (mean +/- 1 SE) ng gastrin/mg tissue. AGC was similar to control values in 18 patients with duodenal ulcer, 14.7 +/- 2.1; 12 patients with a pyloric channel or antral ulcer, 16.4 +/- 3.5; and 48 patients with miscellaneous diagnoses, 14.3 +/- 1.5. AGC was significantly less than control values in 13 patients with a ulcer in the body or fundus of the stomach, 5.9 +/- 1.5, and 4 patients with the Zollinger-Ellison syndrome, 4.9 +/- 2.4. AGC was significantly greater than in control values in 16 patients with gastritis, 25.8 +/- 4.3;22 patients with esophagitis, 23.2 +/- 3.0; and 9 patients with gastric atrophy and fasting serum hypergastrinemia 44.6 +/- 12.3. In group of 77 of these patients with heterogeneous diagnoses, meal-stimulated 3-hr integrated gastrin output was directly related to AGC (r = 0.47, P less than 0.001). In a group of 106 patients AGC was inversely related to histalogstimulated maximum acid output. The correlation was very weak (r = -0.20) but significant (P less than 0.05).

G-cell counts in antral endoscopic biopsies by immunofluorescence

Antral gastrin-producing cell (G-cells) were counted by an immunofluorescence technique in the antral biopsies obtained at endoscopy from 67 subjects; they included patients with duodenal ulcer, gastritis, and individuals with a normal gastric mucosa. The G-cell count was significantly lower (P less than 0.01) in patients with duodenal ulcer (142 G cells per mm2) in comparison to normal subjects (327 G cells per mm2). No statistically significant correlation was found between the G-cell number and any of the other parameters tested (pentagastrin test, basal serum gastrin and its response to a standard meal).

Effect of chronic antacid ingestion on serum gastrin and gastric secretion

Basal gastrin and acid secretion, and histamine- and food-stimulated acid secretion were examined before and after 6 weeks of regular antacid consumption by 20 normal volunteers, in order to test the hypothesis that regular use of antacids produces gastrin cell hyperplasia, altered gastrin inhibition by acid, and gastric hypersecretion. We found no differences in fasting serum gastrin, basal or maximal histamine-stimulated acid, or acid output in response to a protein meal after consumption of commercial antacids with or without calcium carbonate. The results suggest that normal subjects do not acquire functional hyperactivity of the gastrin mechanism after a period of regular antacid use.

Current problems in the measurement of gastrin release. A reproducible measure of physiological gastrin release

The interpretation of gastrin release is confused because of variation in the technique of the radioimmuoassay of gastrin, the lack of a standard stimulus for the release of gastrin and diversity in the method used to express the results. These problems have been analysed (a) by examining the cross-reactivity of three gastrin antisera and using each of the antisera to measure basal gastrin levels in fasting normal subjects, duodenal ulcer and post-vagotomy patients; (b) by determining a satisfactory stimulus for gastrin release in normal subjects; (c) by examining the results to determine the best method of presenting the data. The different a ntisera used were found to give different levels of plasma gastrin in the same sample of plasma. This was not related to the cross reactivity of the antisera. An English breakfast was found to be the most satisfactory stimulus for the release of gastrin. The expression of the results of such a stimulus of gastrin release was affected least by assay variation when the incremental integrated gastrin response was used. It is concluded that the incremental integrated gastrin response to an English breakfast is a satisfactory method for exploring variations in gastrin release.

Gastric carcinoid following gastrojejunostomy

A carcinoid tumor of the gastric body was found in a patient who had a gastrojejunostomy done for duodenal ulcer 36 years earlier. Association of gastric carcinoid with gastrojejunostomy has previously been described by Lemmer. In contrast, such tumors have never been observed when the more common surgical procedure for peptic ulcer was used, ie, gastric resection. On the basis of recent knowledge on gastric endocrine cells, the authors suggest a relationship between the gastrojejunostomy and the carcinoid tumor, probably related to an elevated gastrin release.

Extragastric gastrinoma or G-cell hyperplasia of the antrum? The preoperative diagnosis in a case of hypergastrinaemia

A patient is described with recurrent peptic ulceration, evidence of hypersecretion of gastric acid and excess circulating gastrin. The preoperative differentiation between extragastric "gastrinoma" and G-cell hyperplasia of the pyloric antrum as a source for the hypergastrinaemia can be made by immunofluorescent staining of an antral biopsy for "gastrin cells", and by measuring the response of the gastric antrum to an amino acid meal or secretion infusion stimulus. The site of excessive gastrin production determines the nature of the surgery required. A classification of recurrent peptic ulceration types is suggested.

Hypergastrinemia induced by glucocorticoid and corticotropin treatment in man

To elucidate further the pathogenesis of steroid-induced ulceration, plasma gastrin levels, both basal and after a test meal, were studied in normal volunteers and patients treated with glucocorticoids or corticotropin. In normal subjects the acute intravenous administration of 100 mg prednisolone had no effect on plasma gastrin levels. After oral administration of prednisolone (40 mg daily, for four days) a significant increase of the basal, the reactive, and the over 90-min integrated gastrin release was observed. In this group, the glucocorticoid treatment had a slight, but significant influence on gastric acid and pepsin secretion, while acidity and pepsin output stimulated by pentagastrin was not affected. In patients treated with prednisolone for more than 24 weeks, the oral administration of this hormone failed to alter basal gastrin values but affected significantly secretion after the test meal. In patients with multiple sclerosis, after intramuscular administration of corticotropin (60 IU daily, for 12 days), an increase of the basal, the reactive, and the integrated gastrin release also was found. Glucocorticoid-induced hypergastrinemia provides information on the pathogenesis of steroid-induced ulceration.

Variation in distribution of antral gastrin cells

Using immunoperoxidase technique a considerable variation in the number of antral gastrin cells was demonstrated in patients with atrophic gastritis. This variation must be taken in consideration when the number of gastrin cells is to be estimated on the basis of gastric biopsies.

Neurocristopathy, neuroendocrine pathology and the APUD concept

The neurosecretory cells of the hypothalamus, and the cells of the pituitary gland and the pineal, are here grouped together as a central neuroendocrine division of the APUD series. The larger, peripheral division comprises the remainder of the original series. All the cells are proven or presumptive derivatives of neuroectoderm so that, with the present exception of the parathyroid gland and its products, peptide hormone endocrinology becomes neuroendocrinology. It follows that the pathology of the APUD cell series must be regarded as neuroendocrine and it is suggested that it can best be expressed by the term neurocristopathy (Bolande, 1974). Tumours of the series, properly neurocristomas, are preferably called apudomas because their common cytochemical (APUD) and ultrastructural characteristics provide the pathologist with a ready means of diagnosis.