Ammar Ismail, MD1, Habib Ihtisham, MD2, Hassan Siddiki, MD3 1Jersey City Medical Center, Bayonne, NJ; 2Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 3Cleveland Clinic Foundation, Cleveland, OH Introduction: Zollinger Ellison syndrome (ZES) involves excessive gastric acid production, leading to peptic ulcers and persistent diarrhea. ZES are linked to hypergastrinemia from gastrinomas, typically located in “gastrinoma-triangle” bordered by pancreatic head and duodenal sweep. Around 80% are sporadic, while 20 to 30 % are linked to MEN 1. Surgical resection of these neuroendocrine tumors are recommended, nonetheless, the gastroenterologist need to confirm diagnosis and guide the surgeon towards their anatomical location. We present a case highlighting these keys concepts in the management of ZES.
Case Description/
Methods: A 62 years female with multiple duodenal and jejunal ulcers complicated by jejunal perforation underwent an exploratory laparotomy , small bowel resection and duodenojejunal (DJ) anastomosis . She continued to have GI bleeding with hemoglobin 9.3 g/dl which raised the suspicion of ZES. Patient was not exposed to NSAID and H pylori stool antigen was negative.Upper endoscopy demonstrated more than twenty clean based ulcers in duodenum as well as large ulcers in jejunum (Figure 1). D-J anastomosis was intact and normal. A gastrin level was checked off proton pump inhibitior and was 347 pg/ml . CT Abdomen with contrast did not show any etiology for multiple PUD. Discussion: Zollinger-Ellison syndrome (ZES) is exceedingly rare, with an estimated annual incidence of 0.1–3 cases per million population. It is caused by excess gastrin secretion from gastrinomas, usually in the duodenum or pancreas. Symptoms include peptic ulcers, heartburn, diarrhea, and weight loss. Diagnosis involves fasting serum gastrin and gastric pH; a gastrin >1000 pg/mL with pH < 2 is diagnostic. Secretin or calcium infusion tests are used if inconclusive. Imaging (CT, MRI, EUS, 68Ga-DOTATATE PET) helps localize tumors. PPIs are first-line; somatostatin analogs may help. Surgery is recommended for localized sporadic gastrinomas. In MEN1, surgery is less often curative, and its role remains controversial.
Figure: Jejunal ulcer on upper endoscopy
Figure: Segmental duodenal with NET resection
Disclosures: Ammar Ismail indicated no relevant financial relationships. Habib Ihtisham indicated no relevant financial relationships. Hassan Siddiki: Boston Scientific – Consultant. Conmed – Consultant.
Ammar Ismail, MD1, Habib Ihtisham, MD2, Hassan Siddiki, MD3. P4158 - Unexplained Jejunal Ulcers and Bleeding: A Case of Duodenal Gastrinoma Confirmed by Secretin Challenge, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
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