Zollinger-Ellison Syndrome and Peptic Ulcer Disease

What is Zollinger Ellison Syndrome

Zollinger-Ellison Syndrome is caused by a gastrinoma a gastrin producing tumor, typically in the duodenum
→ the produced gastrin binds to CCKB (CCK2) receptors on the parietal cells and neighboring ECL cells leading to increased HCl secretion and hyperplasia of ECL and parietal cells
→ most often causes peptic ulcers, diarrhea, and esophagitis

How is Zollinger Ellison Syndrome treated?

1) Initial treatment of ZES is via a protein pump inhibitor preventing over secretion of HCl from the Hydrogen Potassium ATPase
→ Pantoprazole is the main PPI used

What inherited disorder is Zollinger Ellison syndrome related to?

25 percent of patients that develop ZES develop Multiple Endocrine Neoplasia-1 or MEN-1
→ MEN-1 is an autosomal disorder for the gene that encodes the nuclear protein menin
→ patients with this disorder often have better 5 year survival rates and the tumors are generally considered more benevolent

What are the two major diagnostic tests related to Zollinger Ellison Syndrome

The two techniques below are used together most commonly
1) Almost all gastrinomas contain somatostatin receptors and can be detected using somatostatin receptor scintigraphy (SRS)
→ but smaller tumors less than 1 cm in size are difficult to localize with this technique

2) Endoscopic ultrasound
→ most commonly used, but fails to detect duodenal tumors often

What is the Secretin Stimulation Test

Diagnostic test for gastrinoma
→ following a fasting period of 12 hours, secretin is administered IV and then their gastrin blood values are measured at specific intervals
→ patients with an increase of 200 pg/mL are considered to have Zollinger-Ellison

What are the most important risk factors for developing Peptic Ulcer Disease

Helicobacter pylori infection

NSAID use

What are the clinical manifestations of Peptic Ulcer Disease and where does it manifest?

The majority of peptic ulcer disease presents as asymptomatic
1) however among symptomatic patients, they most commonly present with epigastric pain along with some form of dyspepsia and abdominal discomfort

2) disease most often manifests in the antrum and lesser curvature because mucus layer is not as thick here?

What are the treatments for Peptic Ulcer Disease

1) Proton Pump Inhibitors (Omeprazole)
→ the main medical therapy, helps to promote ulcer healing through acid suppression

2) H2 Receptor Antagonists
→ limited role in treatment, but may be used in treatment switching off of PPIs for eradication testing of H. pylori

3) Antibiotics
→ clarithromycin being the main one

What are the four most common complications of peptic ulcer disease? What is the most common and how is it treated?

Complications of peptic ulcer disease include bleeding, perforation, penetration and gastric outlet obstruction

→ acute upper gastrointestinal hemorrhage is the most common complication of peptic ulcer disease detected best by endoscopy
→ acute upper gastrointestinal hemorrhaging is treated via endoscopic hemostasis therapies with PPI for 72 hours following treatment

What is Peptic Ulcer Perforation?

A severe complication of peptic ulcers that is penetration of the ulcer through the bowel wall into an adjacent organ marked by severe and acute abdominal pain
→ associated with a triad of abdominal pain, tachycardia, and abdominal rigidity

What is Gastric Outlet Obstruction

The least common complication associated with peptic ulcer disease, and is most commonly associated with a pyloric or duodenal ulcer
→ peptic ulcers causing GI obstruction can cause bloating or nausea

How would you confirm the eradication of H. pylori following quadruple therapy?

Stool antigen testing or urea breath test

Inhibition of organelle _____ would compromise acid secretion

Mitochondria produces the ATP required for the function of the Hydrogen/Potassium ATPase
→ by inhibiting ATP production we inhibit acid secretion

When would stomach pH be at its lowest

In between meals
→ without food buffering the stomach pH, the HCl would cause the pH to drop

What is Melena?

Black tarry stool that turbs black because the blood in the stool is exposed to acid
→ indicative of an upper GI bleed

What is Sucralfate?

Sucralfate becomes viscous when exposed to acid allowing it to be a pseudo-mucous
→ this allows us to buffer acids and binds to proteins at the ulcer base
→ used in preventing further damage to the mucosal wall from pepsinogen and acid

Why does injected epinephrine aid in ulcer bleeding

Epinephrine binding to alpha 1 receptors in the abdominal vasculature would help to stop peptic ulcer bleeding
→ also induces a Tamponade effect which pushes the vessels from all four angles preventing bleeding