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Duodenal Gastrinoma Associated with Multiple Endocrine Neoplasia Type 1 (MEN1) Detected by Esophagogastroduodenoscopy (EGD), which was buried under Ulcer
Kenji Sasaki*
Department of Internal Medicine, Shiogama City Hospital, Japan
- Corresponding Author:
- Kenji Sasaki, MD, PhD
Department of Internal Medicine, Shiogama City Hospital
7-1, Kouzumachi, Shiogama, Miyagi, 985-0054, Japan
Tel: +81-22-364-5521
Fax: +81-22-364-5529
E-mail: kydosarnymai@aria.ocn.ne.jp
Received Date: April 12, 2016; Accepted Date: April 21, 2016; Published Date: April 26, 2016
Citation: Sasaki K (2016) Duodenal Gastrinoma Associated with Multiple Endocrine Neoplasia Type 1 (MEN1) Detected by Esophagogastroduodenoscopy (EGD), which was buried under Ulcer . J Gastrointest Dig Syst 6:418. doi:10.4172/2161-069X.1000418
Copyright: © 2016 Sasaki K. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
A 66-year-old Japanese male was shown to have severe ulcers with hypergastrinemia in the stomach through proximal horizontal part of the duodenum, who complained of dysphagia and vomiting. He suffered from gastric ulcer at 63, proven to have undergone parathyroidectomy for hyperparathyroidism at his 5th decade. Though had no definitely enlarged pituitary detectable by computed tomography (CT), he had slight defects in the visual field and hyperprolactinemia. A diagnosis of MEN1 was entertained. Follow up EGD revealed 5 small sessile submucosal tumors (SMTs) with a central depression or erosion in the duodenal bulb through descending part of the duodenum, which had been obscured beneath ulcers. Demonstrated in the regenerative mucosa by their biopsy were clusters of small tumor cells, which, though considered the tips of neuroendocrine (NE) tumor (NET) lying in the deeper layer, were not large enough to be proven so by immunostaining with the markers in the serial sections, and diffuse hyperplasia of synaptophysin-, chromogranin A- and gastrin-positive NE cells in Brunner glands (BGs), the preneoplastic lesion characteristic of MEN1-associated duodenal gastrinoma, supporting the diagnosis, which was firmly guaranteed by positively elevated glucagon-provoked plasma gastrin. Subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) established the final diagnosis of duodenal gastrinomas graded G1 associated with MEN1, which were shown to be tightly contained in the densely conglomerated hyperplastic BGs. No metastases were detected. This is the first case in the world, in which all the three characteristics of MEN1- associated duodenal gastrinoma were demonstrated by EGD. Difficulty in endoscopically detecting the NET lies in the fact that, in addition to its smallness and deep localization, it might be buried under peptic ulcer at a certain stage of the natural history and that an attempt to biopsy it is hampered by the densely conglomerated barrier of the hyperplastic BGs in some cases.
