Post on 15-Jul-2015
ZOLLINGER-ELLISON SYNDROME
(Mr. Lim case problem)
MD-2508 (DIGESTIVE SYSTEM)PROBLEM BASED LEARNING (PBL)
DR. FATMA S.A. SAGHIR
TRIGGER 1
• Mr. Lim (Man), 47 Y/O (Adult), House painting business
• Main complain : abdominal pain ass. Diarrhea
• Referred to Physician, endoscopy shows ulcer in duodenal bulb
• Ct scan shows 3cm mass on head of pancrease• Thought to be gastrinoma• Omeprazole prescribed• Undergo laparoscopic surgery
TRIGGER 2
TRIGGER 3
9 questions to ask about pain
S – Site of the pain
O – Onset of the pain
C – Characteristic of the pain
R – Radiation of the pain
A – Association of the pain
T – Time course of the pain
E – Exacerbating/relieving factor
S – Severity of the pain
SIGN OF GIT
Inspection
- Abnormal abdominal structure
- Skin have hemangioma or dilated vein
- Mass
- Asymmetry motion during respiration
- Herniation during cough
- Anal fissures or hemorrhoids
Auscultation- Abnormal bowel
sounds- Rub and bruits
soundPalpation- Tenderness of
visceral organ- Nodularity on
liver- Mass- Change in size of
visceral organPercussion- Ascites
Dehydration- Decrease in skin turgor - Dry mucous membranes-Less tears and urine (babies)- Increased pulse- Decreased blood pressure-Delayed capillary refill
General symptom GIT disorder
• Constipation (painful bowel movement)
• Abdominal pain (indigestion)
• Diarrhoea (acute & chronic)
• Gas in GI tract (bloating)
• GI bleeding ( peptic ulcer )
• Nausea
• Vomiting
Gastric Ulcer Duodenal Ulcer
Occur in the stomach. Occur in the duodenum.
Abdominal pain cannot be relieve by eating.
Abdominal pain can be relieveby eating.
Epigastric pain 1-2 hours aftereating.
Epigastric pain 2-5 hours after eating.
Can cause melena or haemetemesis.
Can cause melena or hematochezia.
Pain are less likely awaken patient at night (30-40%.)
Pain often awaken patient during the night (50-80%).
Peptic ulcer
Chronic use of NSAID or
aspirin
Steroids
Smoking
Helicobacter pylori
Duodenal ulcer
Helicobacter pylori
↑ gastric secretion
↑ rate of gastric
emptying
Blood group o
Cirrhosis
COPD
Signs & Symptoms
Zollinger –Elison
Syndrome
Peptic Ulcer Pyloric Obstruction
Gastric cancer
Indigestion / / / /
Loss of appetite / / / /
Abdominal pain / /
Oily diarrhoea /
Ulcer in duodenum
/ / /
High gastrinlevel
/ /
1. Cholecystitis
• inflammation of the gallbladder (mostly by gall stones)
• Gallstones stuck in the cystic duct
• When eating, bile is produced then builds up in the gallbladder
• bladder becomes stretched then lead to inflammation
2. Diverticulitis
Diverticulitis happens when feces get trapped in the pouches (diverticula). This allows bacteria to grow in the pouches. This can lead to inflammation or infection.
causes are idiopathic,
Diverticulitis can be very painful.
1. duodenal Ulcer
• Imbalance amount of acid produced and mucosal barrier of duodenum acid damage duodenum ulcer develop food ingested food contain some bases neutralise acid at duodenum decrease Inflammation
2. Gastritis
• Imbalance amount of acid produced and mucosal barrier of stomach acid damage stomach food ingested gastric acid act on food decrease Inflammation
Definition :
Passing of stools that contain a high amount of fat.
Symptom :
• Fatty Stools
• Float stools
• Pale Color
• Foul Smell
• Weight Loss
• Heavy Stools
Causes :• Bile Acid Deficiency
• Defects of Pancreatic Enzymes
- Pancreatitis - Inflammatory bowel disease
- Cystic fibrosis - Gastrointestinal surgery
• Indigestible Fats
• Medicines
- Drugs like Orlistat can block the enzymes that digest
fat components in the diet..
• Poor Absorption of Nutrients
• Excessive Alcohol Consumption
- Too much consumption of alcohol for a very long time can
damage tissues in the pancreas and cause
scarring and swelling
• Gastrin hormone test (Mr Lim got high level : 800pg/ml)
-to detect excess production of gastrin.
-to diagnose gastrin producing tumor, peptic ulser and G-cells
hyperplasia.
-low: usually are off concern.
high: ZE syndrome, G-cells hyperplasia.
low after surgery then high: recurrance of tumor.
• Basal Gastric H+ secretion (Mr Lim got high rate : 100mEq/hr)
- Measure acid secretion in fasting state.
- Completely absence: pernicious anemia.
- Decreased: gastric cancer.
- Increase: ZE syndrome.
• Pentagastrin stimulation test (Mr Lim: No increased in H+
secretion )
- to test basal and stimulated acid production by the parietal cells of the stomach.
- Low: achlorhydia*.
High: ZE syndrome
• Secretin stimulation test (Mr Lim: the serum gastrin increased
to 1,100pg/mL)
- To measure pancrease ability towards secretin.
- stimulates gastrin release in patients with gastrinoma.
- small changes in serum gastrin concentrations occur patients with peptic ulcer.
GASTRINOMA (gastrin-secreting tumor)
Gastrinoma is one of the type of neuroendocrine tumor
This tumor will produce large amounts of gastrin
Neuroendocrine tumours (NETs) are tumours that develop in cells that are triggered by nerve cells to produce hormones.
People who have a rare family cancer syndrome called Multiple Endocrine Neoplasia Type 1 (MEN 1) have a higher risk of gastrinoma
Manifestation
1. Usually idiopathic PUD (75%)- Haemorrhage, perforation and obstruction are common complications.
2. May get diarrhoea (25%)- from the acid (destroys lipase and produces steatorhoea).
Often delayed diagnosis- mean time of symptoms to diagnosis is 5 years.
Suspect if:Diarrhoea, pain and weight loss.Recurrent or refractory ulcersProminent rugal folds (trophic effect of gastrin)GI symptoms in an MEN-1 patient
Large amount of gastrin produced
Too much stomach acid produced
damage to the mucosal lining of the GI tract
May form peptic ulcer in stomach or duodenum
acid inactivates pancreatic enzymes, which contributes to the diarrhoea, steatorrhoea, and malabsorption
COMPLICATION OF ZES• May have only one gastrinoma or may have
several.
• ZES patients who have multiple endocrine neoplasia type 1, can cause tumors in the pituitary and parathyroid glands.
• Gastrinomas can be malignant (cancerous). These malignant gastrinomas can spread to other parts of the body, including the liver, lymph nodes, spleen, bones, or skin.
• Bleeding, perforation, and obstruction
ANTACIDS
• Neutralize acidity ,, acidity• Relieve sign & symptom(pain)• Treat DU(naturally in high dose&sufficientduration)• Less effective in Gastric ulcer• Systemic-NaHCO3• Non systemic-(Mg,Al,Ca)compund• Over counter antacid-Eno,Gaviscon,Alucid• At hospital,pharmacy-Mg
trisilicate,Omelon,Zantac
NAME TRADE NAME: Acimax, Antra, Aspra, Gastroloc, Losec, Losectil, Lozeprel, Mopral, Olex, Omepral, Omez, Opal, Ozid, Prilosec, Rome 20, Segazole, Ulcozol, Zegacid, Zegerid.
CHEMICAL NAME: 6-methoxy-2-[(4-methoxy-3,5-dimethylpyridin-2-yl)methanesulfinyl]-1H-1,3-benzodiazole
DOSE 20mg once daily for 4 weeks in DU, 8 weeks in GU
40mg once daily for recurrent or severe case
ALTERNATIVE Esomoprazole, lansoprazole, pentoprazole,rabeprazole,
SIDE EFFECT - Nausea, abdominal pain, constipation- Subacute myopathy, arthralgia, headache, skin rash
MECHANISM OF ACTION
Permanent (irriversable)
inhibition of H+, K+ -ATPase
(proton pump) of gastric parietal
cells, selectively inhibit gastric
mucosal carbonic anhydrase