A case of Zollinger-Ellison syndrome diagnosed by duodenal ulcer perforation into the gallbladder

摘要

A 79-year-old woman presented with abdominal pain. Because of epigastric discomfort she had taken rabepra-zole (10 mg/day) for 7 years and had discontinued it 3 weeks previously. She had no history of peptic ulcer disease, nonsteroidal anti-inflammatory drug ingestion, or Helicobacter pylori infection. Laboratory examination showed a white blood cell count of 8150/mm3, hemoglobin of 12.7 g/dL, platelet count of 260,000/mm3, and C-reactive protein of 5 mg/L (<4 mg/L). EGD revealed multiple ulcers in the second part of the duodenum, including a perforation with surrounding yellow mucus (A, arrow). An abdominal CT scan (B) showed pneumo-gallbladder (arrow), circumferential thickening of the duodenal and gallbladder walls, a 3-cm lymph node posterior to the third part of the duodenum (arrowhead), and small liver nodules. A serum fasting gastrin level was 420 pg/mL (<200 pg/mL). We diagnosed a post-bulbar duodenal ulcer that had created a fistula into the gallbladder, and we administered intravenous omeprazole 20 mg twice daily. At surgery, we performed fistula closure, cholecys-tectomy, lymphadenectomy, and intraoperative liver biopsy for definitive diagnosis (C). Histologic examination showed a gastrinoma with liver and lymph node metasta-ses, which stained positive for gastrin (D). The patient was discharged on maintenance rabeprazole 10 mg daily and recently started monthly therapy with octreotide long-acting release (LAR) (somatostatin analogue). She remains symptom-free 5 months after surgery.