Mr. Lim, a 47-year-old man, presented with abdominal pain and diarrhea. Endoscopy revealed a duodenal ulcer and CT scan showed a 3cm pancreatic head mass suspected to be a gastrinoma. Laboratory tests found highly elevated gastrin and basal gastric acid levels consistent with Zollinger-Ellison Syndrome. Further tests demonstrated increased gastrin response to secretin stimulation, confirming a gastrin-secreting pancreatic tumor as the cause of his symptoms. Complications of ZES include peptic ulcers, diarrhea from excess acid inactivating pancreatic enzymes, and potential malignant spread of gastrinomas. Omeprazole was prescribed to reduce gastric acid levels and treat his

1. ZOLLINGER-ELLISON
SYNDROME
(Mr. Lim case problem)
MD-2508 (DIGESTIVE SYSTEM)
PROBLEM BASED LEARNING (PBL)
DR. FATMA S.A. SAGHIR

2. 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

3. 9 questions to ask about
pain

4. 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

5. Sign of
GIT

6. 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
sound
Palpation
- Tenderness of
visceral organ
- Nodularity on
liver
- Mass
- Change in size of
visceral organ
Percussion
- Ascites
Dehydration
- Decrease in
skin turgor
- Dry mucous
membranes
-Less tears and
urine (babies)
- Increased pulse
- Decreased
blood pressure
-Delayed
capillary refill

7. GENERAL GI
SYMPTOMS

8. 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

9. DIFFERENT
BETWEEN
GASTRIC ULCER
AND
DUODENAL ULCER

10. Gastric Ulcer Duodenal Ulcer
Occur in the stomach. Occur in the duodenum.
Abdominal pain cannot be
relieve by eating.
Abdominal pain can be relieve
by eating.
Epigastric pain 1-2 hours after
eating.
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%).

11. Underlying
causes of peptic
ulcer &
duodenal ulcer

12. 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

13. Differential Diagnosis

14. Signs &
Symptoms
Zollinger –
Elison
Syndrome
Peptic Ulcer Pyloric
Obstruction
Gastric
cancer
Indigestion / / / /
Loss of appetite / / / /
Abdominal pain / /
Oily diarrhoea /
Ulcer in
duodenum
/ / /
High gastrin
level
/ /

15. PAIN THAT
WORSEN
AFTER EATING

16. 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

17. 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.

18. PAIN THAT
RELIEVE BY
EATING

19. 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

20. 2. Gastritis
• Imbalance amount of acid produced and
mucosal barrier of stomach acid damage
stomach food ingested gastric acid act
on food decrease Inflammation

21. Noted: Mr Lim suffered diarrhea (looked oily)
STEATORRHEA

22. Definition :
Passing of stools that contain a high amount of fat.
Symptom :
• Fatty Stools
• Float stools
• Pale Color
• Foul Smell
• Weight Loss
• Heavy Stools

23. 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

24. LAB REPORT
(investigation)

25. • 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.

26. • 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.

27. Causes of tumor
& Gastrinoma

28. What causes tumor ?

29. 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

30. 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 ulcers
Prominent rugal folds (trophic effect of gastrin)
GI symptoms in an MEN-1 patient

31. 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

32. COMPLICATION OF
ZOLLINGER-ELLISON
SYNDROME

33. 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

34. antacid

35. ANTACIDS
• Neutralize acidity ,, acidity
• Relieve sign & symptom(pain)
• Treat DU(naturally in high dose&sufficient
duration)
• 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

36. zantac
omelon
• omelon-omeprazole,Zantac-ranitidine(has
antacid action)

37. omeprazole

38. 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