Zollinger-Ellison Syndrome

 Hypervascular pancreatic mass with multiple peptic ulcers and thickened folds



• Best imaging tool
image Helical CT or MR for pancreas and possible metastasis

image Endoscopic ultrasonography for additional primary sites; guides biopsy




TOP DIFFERENTIAL DIAGNOSES




• Helicobacter pylori gastritis

• Gastric carcinoma

• Gastric metastases and lymphoma

• Extrinsic inflammation

• Other gastritides


PATHOLOGY




• 20-60% of cases are associated with multiple endocrine neoplasia type 1 (MEN1)


CLINICAL ISSUES




• Most common signs/symptoms
image Pain, increased acidity, severe reflux, diarrhea, upper gastrointestinal tract ulcers

image Gastrinomas are often multiple (60%), malignant (60%), and metastatic (30-50%)

• Hypergastrinemia is hallmark of Zollinger-Ellison syndrome (ZES)
image Serum gastrin level of > 1,000 pg/mL is virtually diagnostic of ZES

• Prognosis
image Good with surgical resection of primary gastrinoma

image Poor if gastrinoma, liver metastases, or ulcers recur after surgery

image
(Left) Axial CECT in a 63-year-old man who presented with intractable peptic ulcer disease demonstrates hyperemia and mural thickening image of the stomach.


image
(Right) Arterial phase CECT in the same patient shows a small hypervascular gastrinoma image in the pancreatic head. It is important to distinguish this from the superior mesenteric artery image and superior mesenteric vein image.

image
(Left) Axial CT of a 55-year-old woman with hypercalcemia, diarrhea, and severe abdominal pain as presenting symptoms of MEN1 syndrome shows one of several neck masses image, representing parathyroid adenomas or hyperplasia.


image
(Right) Abdominal CT in the same case shows marked hypervascularity and thickening of the gastric wall image. Multiple liver metastases are present image. The serum gastrin levels were strikingly elevated, confirming ZES, though the gastrinoma was not identified on CT.


TERMINOLOGY


Abbreviations




• Zollinger-Ellison syndrome (ZES)


Definitions




• Severe peptic ulcer disease associated with marked ↑ in gastric acid due to gastrin-producing endocrine tumor (gastrinoma) of pancreas


IMAGING


General Features




• Best diagnostic clue
image Hypervascular pancreatic mass with multiple peptic ulcers and thickened folds

• Location
image Gastrinoma: Pancreas (75%), duodenum (15%), and liver and ovaries (10%)
– Common site: Gastrinoma triangle
image Superiorly: Cystic and common bile ducts

image Inferiorly: 2nd and 3rd parts of duodenum

image Medially: Junction of pancreatic neck and body

image Ulcers: Stomach and duodenal bulb (75%), postbulbar and jejunum (25%)


Radiographic Findings




• Barium studies: Gastric, duodenal, and proximal jejunum
image Large volume of fluid dilutes barium and compromises mucosal coating

image Markedly thickened gastric folds

image Peptic ulcers: Round or ovoid barium collections surrounded by thin or thick radiolucent rim (edematous mucosa) and radiating folds


CT Findings




• Gastrinomas
image Small or large, heterogeneous density lesion, ± cystic and necrotic areas, ± calcification

image Liver metastases are common

image Hypervascular (primary and secondary) lesions ± local or vascular invasion on arterial and portal venous phase

image Inflammatory changes in stomach, duodenum, and proximal small bowel
– Thickened gastric, duodenal, and jejunal folds

image Signs of ulcer penetration
– Wall thickening, luminal narrowing of stomach and duodenum

image Signs of ulcer perforation
– Free air in abdomen (from a duodenal or antral ulcer) or lesser sac (from a gastric ulcer)


MR Findings




• T1WI
image Hypointense pancreatic nodule on fat-saturated sequence

• T2WI
image Hyperintense on spin-echo sequence
– Both primary and metastatic tumors

• T1WI C+
image Hyperintense, hypervascular on fat-saturated delayed spin-echo sequence


Ultrasonographic Findings




• Endoscopic ultrasonography (EUS)
image Detects small gastrinomas better than CT or MR

image Usually homogeneously hypoechoic mass

• Intraoperative ultrasonography
image Detects very small tumors (75-100% sensitivity)

Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Zollinger-Ellison Syndrome

Full access? Get Clinical Tree

Get Clinical Tree app for offline access