The diagnosis and management of gastrinoma

Initial reports of patients with Zollinger-Ellison syndrome were characterized by a long history of recurrent peptic ulcer and multiple operations. Diagnosis was usually made by a combination of clinical history and roentgenograms of the upper aspect of the gastrointestinal tract. Diagnosis was confirmed by the demonstration of elevated basal plasma gastrin levels. The management of the disease included either tumor excision or gastric resection, but more often it included a total gastrectomy. The mortality was high, often because of late recognition of the disease or operative problems related to inadequate control of the hypersecretion of acid. This review is a brief synopsis of the evolution and status of the different diagnostic and therapeutic techniques involved in the contemporary management of patients with gastrinomas. The diagnostic emphasis has shifted away from gastrointestinal contrast studies. Techniques have been developed both for the biochemical diagnosis of the condition and for the topographic localization of the site of the lesion. The use of acid secretory data has declined in value with the development of more elegant techniques for the detection of elevated levels of plasma gastrin in the systemic circulation and the use of portal venous sampling for identifying the source. Thus, the results of sophisticated procedures such as percutaneous transhepatic portopancreatic venous sampling or selective angiography provide additional information. The biochemical diagnosis of gastrinoma is best supported by the evaluation of provocative testing with either calcium or secretin rather than measurement of the basal levels of plasma gastrin. The introduction of potent H2 receptor antagonists has produced support for more conservative management of the disease. The incidence of significant complications during such therapy limits its over-all efficacy. The use of these drugs has, however, facilitated both the conservative and the operative management of patients with extensive sequelae of acid hypersecretion due to a gastrin-secreting tumor. It is probably reasonable to surgically stage the disease of all patients with hypergastrinemia of neoplastic origin since a small percentage (10 per cent) may have a solitary benign lesion which is curable by resection. Total gastrectomy under elective circumstances still has considerable merit. Preliminary data have indicated that alternative, lesser surgical procedures, such as proximal gastric vagotomy, may be therapeutic options if the patient is compliant and sensitive to the appropriate dosage of H2 receptor antagonist.(ABSTRACT TRUNCATED AT 400 WORDS)