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home - Stomach - Peptic Ulcer Disease - Zollinger Ellison Diagnosis Written by Dr Sebastian Zeki

Knows the range of organic and non-organic causes of dyspepsia. Be
aware of current BSG and NICE guidelines for selecting patients for
investigation. Know the significance of alarm symptoms
Understands the relevance of Helicobacter pylori infection and how it
can be detected and treated.
Recognise the adverse effect of nonsteroidal anti-inflammatory drugs
Understands the physiology of gastric acid secretion, mucosal
protection and gastroduodenal motility and know how drugs can
modify these
Knows the complications of ulcer disease, the principles of surgery
that may be required and be aware of post-operative sequelae

Makes a thorough clinical assessment, perform appropriate
investigations and be familiar with how medical treatments are used.
Show awareness of how to recognise and manage complications

Can explain the steps taken towards making a diagnosis and
planning treatment clearly and comprehensibly


Knows the causes of upper gastrointestinal bleeding and its
Understands the circulatory disturbance associated with blood loss
and the pathophysiology underlying the clinical manifestations of
hypovolaemic shock
Knows the principles of assessing hypovolaemia and of restoring the
circulation. Be able to identify and correct coagulopathy
Knows the principles of using the various risk stratification tools SCE 1
Knows how endoscopic techniques are used to control bleeding CbD, DOPS, SCE 1
Understands how oesophageal and gastric varices develop and the
endoscopic and pharmacological methods that are used to control
blood loss

Can make an accurate clinical assessment, and stratify the risk. Know
the principles of fluid resuscitation and arrange endoscopy
Is aware of methods to secure haemostasis, recognise signs of rebleeding and liaise with other disciplines (such as interventional
radiology or surgery

Assesses and treats patients who have bleeding with appropriate
degree of urgency.


Understands why part or all of the patient’s stomach is removed and
the altered post-surgical anatomy

Understands the problems of a gastro-enterostomy and a Roux-en-y

Has awareness of dumping syndromes
Knows the various surgical operations performed for obesity (bariatric
surgery) and their complications

Can give nutritional advice and choose the appropriate method by
which an enteral feeding tube is inserted into the small bowel

Can initiate the use of pancreatic enzyme therapy
Has ability to recognise and treat early and late dumping syndrome
Able to help the patient carers friends and family understand how
the patient can be encouraged to gain weight

Works closely with dieticians and surgical colleagues

Zollinger Ellison Diagnosis

Suspect Gastrinoma Serum gastrin off PPI for 1 week Diagnosis Suspect Other Diagnostic Tests:Serum chromogranin AMarker of any neuroendocrine tumour.Increased in most gastrinomas and level correlates with tumour volumeIndication: Confirmatory test in difficult cases (normal in secondary hypergastrinaemia).Calcium infusion studyIndication: Gastric acid hypersecretion with high suspicion of gastrinoma despite a negative secretin test.Method: Infuse calcium gluconate (5 mg/kg/hr for 3 hours) and determining serum gastrin levels every 30 minutes.Infusion is associated with an increase in serum gastrin levels in patients with gastrinoma.Positive responses are usually observed between 120 and 180 minutes.Using a change in calcium of ≥50 % as the cutoff, the sensitivity and specificity were 78 and 83 %, respectively. Secretin stimulation test Is indicated if the patient has a nondiagnostic fasting serum gastrin concentration.It stimulates the release of gastrin by gastrinoma, and inhibits gastrin release in normal G-cells.A positive test is when the serum gastrin rises by >200 pg/mL= +ve test (peaks within 10 mins). > 1000 pg/mL > 110 to <1000 pg/mL Differential of hypergastrinaemia:Renal insufficiency.Massive small bowel resection.G-cell hyperplasia.Gastric outlet obstruction.Retained gastric antrum.Potent antisecretory drugs. Serum gastrin concentration A gastric pH <5.0 + serum gastrin value > 1000 pg/mL (475 pmol/L) is diagnostic of the disorder.Gastric pH measurement is needed to exclude 2ndary hypergastrinemia due to achlorhydria.2/3rds of ZE have [serum gastrin] <10x upper limit of normal.Higher levels are more likely with pancreatic (compared with duodenal) tumors, larger tumor size, and with mets. Clues suggesting gastrinoma:Multiple PUD.Post bulbar ulcer.PUD + diarrhoea.Unexplained refractory diarrhoea.Large gastric folds.Personal/ family history of hypercalcaemia/ pituitary tumour.Recurrent PUD after surgery.PUD refractory to conventional dose PPI. Zollinger-Ellison Syndrome Diagnosis Written by Dr Sebastian Zeki

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