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------=_NextPart_01C68EEF.AA785AA0 Content-Location: file:///C:/85899F85/ZE_files/master05.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C68EEF.AA785AA0 Content-Location: file:///C:/85899F85/ZE_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C68EEF.AA785AA0 Content-Location: file:///C:/85899F85/ZE_files/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Z-E
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Anthony Catapano, MS IV
NYCOM
March 3, 2006
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<= span style=3D'font-size:86%;color:#FFCC66;mso-color-index:3'>lCC:  = 220;I have belly pain and dark brown vomit for 1 week.” =
lHPI:  77 = y/o Male c/o diffuse abdominal pain X1 week.  Pain has been increasing in severity;  is n= ow 10/10 and continuous.  Pt. also c/o 10-15 bouts of dark = brown vomit during this time.= Pt. states that he has had similar episodes 4-5X in the past.=   Pt. denies diarrhea, but recounts 2 episodes of loose BMs.  Pt. denies blood in stool.  Pt. denies dizziness, fever, CP, SOB, urinary complain= ts or sick contacts.
77 y/o male BIBEMS
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lPMH:=  
–HTN =
–A-fib= 3;
–Chronic Pancreatitis
–Hep C= 3;
–CVA =
–COPD = ;
–Prostate CA
–CAD = ;
–Hx. Of U= GI bleed
lPSH:
–CABG (20= 01)
–Prosthet= ic MVR
–S/P IVC = filter
–S/P Left Gastric arterial embolization for UGI bleed
–
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lMedications: <= /div>
–Lopressor 50mg BID
–Lisinopril 80mg daily
–Clonidine 0.1mg BID
–Percocet 5/325mg tt Q4hrs PRN pain
–FeSO4 325mg TID
–MVI
lAllergies:  NKDA
lSocial Hx:  former smoker (quit 20yrs ago);  former EtOH, denies drugs
lFH:  Denies
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Physical Exam:
lVS:   T: 97.4  P: 80  R: 18  BP: 134/85
lPE:
–GEN:  AAOX3;  no acute resp distress; deshevele= d appearance
–HEENT:  +L eye prosthesis;  neck supple, -LAD
–= LUNGS:  CTA B/L;  -W/R/R
–= CV:  +S1,S2, irregularly irregular = ;
–CHEST:  +midline scar extending to below umbilicus
–ABD:  +midline scar, NABS, soft, +diffu= se tenderness, ND, no guarding/rebound;  rectal: Guaic+
–= EXT:  -C/C/E, -calf tenderness
–= NEURO:  - focal deficits
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Differential Diagnosis:
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Differential Diagnosis:
lPeptic Ulcer Disease
–Secondar= y to: NSAIDS, H. pylori
lBowel obstruction
lEsophageal Varices
lMallory-Weiss tear
lCancer:  Gastric, pancreatic.
lErosive gastritis (NSAIDS, EtOH, stress)
lErosive esophagitis
lVascular ectasias (angiodysplasias) e.g. AVM, CRES= T
lAortoenteric fistula
l
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Labs:
lCBC:  BMP:
l= 12.2     MCV:  99.2 139     95=         15      <= /span>139
–6.8          281 3.1    35   &n= bsp; 1.5
– = 35.9     N:  78.3         = ;         8.9
–Previous visit H/H:  11.1/32.6
–
–13.5         29.3 LFT:  2.5/6.7/62/48/1.6/0.7/95
–    = CE:  CPK: 25 CKMB:  1.8         = ;     1.4   Trop: 0.13
– =  
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Labs: (continued)
lMg: 1.6
lPhos: 2.0
lCEA:  1.2
lGastrin (2/18):&n= bsp; 1503
lCA 19-9:  (2/18):  209
lIonized Ca+: 4.98
lVit. B-12:  = 1104
lFolic Acid:  5.8
lAmylase: 95
lLipase: 16
lPTH, Prolactin:&n= bsp; Pt. refused blood draw
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Imaging Studies:
lCXR (2/16):  no active pulmonary disease;
–+ enlarged cardiac silhouette
lCT abd:  (01/25/06): no evidence of intestinal iscehmia; +hypodense areas o= f the head of pancreas, underlying malignancy cannot be ruled out; +B/L renal artery stenosis; +Diverticulosis
lEGD  (1/25/06):  10cm segme= nt (33-43cm) erosive mucosa w/ large pouch distal to the GE junction;&nb= sp; multiple clean based = large ulcers in duodenal bulb
–Esophage= al Bx:  ulcer w/ candida organis= ms and purulent exudate
lWhole body Bone Scan: (1/25/06): no evidence of mets
l&= #13;
–
–
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Patient Management:
lPt was admitted to 6N
lDx:  = abd. Pain/ UGI bleed
lMeds: 
–Nexium 4= 0mg PO daily
–KCl 10 m= eq in 100ml NS IVPB X2 doses, 1hr apart
–Lopresso= r 25mg PO BID (hold if BP<110/70)
–Clonidine 0.1mg PO BID (hold if BP<110/70)
–Percocet 5/325mg tt PO Q6 hr PRN pain
–Lisinopr= il 40mg PO daily
–MVI t PO daily
–Ferrous Sulfate 325mg PO TID
lDVT prophylaxis:&= nbsp; Flowtron boots
l&= #13;
l
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Zollinger Ellison Syndrome
Anthony Catapano, MS IV
NYCOM
March 3, 2006
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Introduction
lDefinition:  Severe peptic ulcer predispositio= n secondary to gastric acid hypersecretion due to unregulated gastrin release from a non-beta cell endocrine tumor (gastrinoma).= 3;
lFirst recognized in 1955, by Dr.’s Zollinger and Ellison:
–   = they characterized a syndrome of ulceration of the upper jejunum, hypersecretion of gastr= ic acid, and non-beta islet cell tumors of the pancreas
lUnlike typical peptic ulcer disease, ZES was often aggressive, persistent, and life-threatening
lthe hallmark is the excess secretion of gastrin
–Leading to increased PUD
–>90% of pts. w/ ZES develop P= UD
– =
–
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General Considerations
lIncidence (U.S.): 0.1 to 1 percent of patients= with PUD
–May be underestimated:  clinically may appear indistinguishable from other causes of PUD (NSAIDS, H. pylori)
lMales>Females
lUsually diagnosed between ages of 30-= 50
lMost are solitary lesions or multifocal nodules that are resectable
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MEN 1
l25% of gastrinomas are associated w/ MEN 1
–Associated w/ tumors or hyperp= lasia in 2 or more endocrine glands
–m/c parathyroid: 87%
–Followed by pancreatic: 81%= 3;
–Pituitary: 65%
–Others:  adrenal cortex, thyroid glands &#= 13;
–(multicentric gastrinomas) tha= t are difficult to resect
–Will also see elevated Ca, PTH, prolactin levels
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Location
l80% of gastrinomas are found inside the gastrinoma triangle
–- Confluence of cystic duct and CBD
-Junction of 2nd= /3rd=  part of duodenum
-Junction of Neck/body= of pancreas
The gastrinoma triangle
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mCQeVbjKnkW6A9PXFFFFaQRz1m21c//Z ------=_NextPart_01C68EEF.AA785AA0 Content-Location: file:///C:/85899F85/ZE_files/slide0028.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Z-E
Location
lMost common sites:
–#1)  Pancreas
–#2)  Duodenal wall
–#3)  = Lymph nodes
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Pathophysiology
<= span style=3D'font-size:88%'>lAutonomous neoplasm (gastrinoma) secretes gastrin
lGastrin binds to gastrin receptors on parietal cells, stimulating acid secretion. lGastrin also induc= es histamine release from Enterochromaffin-like (ECL) cells, which also stimulates acid secretion. lIncreased gastric acidà PUD, erosive esophagitisà complications of hemorrhage or perforation
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Pathophysiology
lIncreased gastric a= cidà diarrhea
–= Volume overload &agrav= e; small intestine/lg intestine cannot reabsorb
–Damage to mucosa of small intestineà sloughed off cells
–Pancreatic enzymes are inactivated (pancreatic lipase) by lower pHàimpair= ed hydrolysis of fatsàsteatorrhea, weight loss
lLow pHà decre= ased B12 absorption
–
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Clinical Manifestations
l90% of ZES pts have PUD
–May be indistinguishable from other causes of PUD
–More sev= ere form of PUD, refractory to medical tx.
–Usually solitary, <1cm
–75 perce= nt – 1st portion of the duodenum,
l= 14 percent in the distal duodenum
l=  11 p= ercent in the jejunum
lDiarrhea:  33% of pts
lMetastatic disease
–one-thir= d of patients with a gastrinoma at the time of diagnosis
lNIH study:  mean delay between sx. onset and diagnosis was 5.2 years
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Clinical Manifestations
lSuspect ZES:
–PUD pt that is refractory to medical tx.
–Multiple ulcers or ulcers in unusual locations = ;
lE.g.:  3rd= /4th=  portion of duodenum, or jejunum= 3;
–Recurrent ulcers after surgical procedures that would normally cure the ulcer diathesis
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Labs
lFasting Serum Gastrin
–HYPERGASTRINEMIA:
–>200pg/mL
–Most have >500pg/mL
–Can be as high as 10,000pg/ml
–Most sensitive and specific
–Pts. Should not be on H2 blockers/PPIs for 6 days prior to study
–
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Labs
lSecretin Provocative Test
–Done as confirmatory test when gastrin is 200-500pg/mL
–2units/kg secretin bolus given
lA rise in serum gastrin >200pg/mL within 15min <= /span>
l= or
lDoubling of fasting gastrin level
l=
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Labs
lMEN 1 should be excluded:
–Calcium
–PTH
–Prolactin
–FSH,LH
–GH levels
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Imaging Studies
l 
lUGI series:  may demonstrate ulcers lAbd = CT:  may localize tumor
<= span style=3D'visibility:hidden'>l
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