A classical case of Zollinger-Ellison syndrome
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The present case has been reported in the journal Gastrointestinal Endoscopy.

A 64-year-old man presented with watery diarrhea and 40-pound weight loss. He has a history of gastroesophageal reflux disease and esophagitis seen in upper endoscopy done previously. His epigastric discomfort and heartburn symptoms were getting worse with eating and were poorly responsive a daily dose of 40 mg oral omeprazole. The diarrhea was not improving in response to fasting. He denied dysphagia or odynophagia.

Laboratory workup showed fasting gastrin level 669 pg/mL, serum chromogranin A 100 ng/l and gastric PH at 1. A CT scan with contrast of the abdomen and pelvis showed a normal pancreas. However, it revealed multiple, solid with cystic component liver lesions that are compatible with metastatic disease. CT-guided core-needle liver biopsy revealed metastatic well-differentiated neuroendocrine carcinoma/carcinoid tumor. The primary tumor was undetermined.

Upper endoscopy demonstrated diffuse erosive inflammation of the second part of the duodenum. Closer endoscopic look underwater magnification showed the hypertrophied parietal cells. Duodenal biopsy was consistent with chronic peptic duodenitis with no evidence of dysplasia or malignancy.

EUS demonstrated a single, well-defined 2x2, round, hypoechoic, heterogeneous solid mass in the head of the pancreas. The outer margin of the mass was slightly irregular. EUS also revealed a gastric wall thickening. Beside the physiologic uptake in the kidneys and the spleen, the pentetreotide scan demonstrated intense focal uptake in a 2.3 cm soft tissue related to the ventral surface of the pancreatic head, consistent with malignancy.

It also revealed multiple radiotracer avid liver metastases. The patient was treated with long-acting octreotide 30 mg and experienced relief of symptoms.

Source: https://www.giejournal.org/article/S0016-5107(19)30069-0/pdf