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

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

Skills
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

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

Also....

Knowledge
Knows the causes of upper gastrointestinal bleeding and its
presentation
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

Skills
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

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

Also...
Knowledge


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
anastomosis

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

Skills
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
Behaviours
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 Treatment

Prognosis—The level of fasting serum gastrin (FSG) at the time of initial diagnosis may provide an indication of disease extent and estimated prognosis in patients with sporadic ZES.The five-year survival rates for patients based on their FSG areMild (0 to 499 pg/mL) 94%Moderate (500 to 1000 pg/mL) 92%Severe elevations (>1000 pg/mL) 86% Liver mets No liver mets Surgical exploration ? if pancreatic tumour > 2cm Negative for MEN1 Positive for MEN1 Medical treatment Somatostatin receptor imaging with 111-Indium-penetreotide (Octreoscan) and SPECT- Best sensitivity. Good for metsEUS for small pancreatic endocrine tumors- can also get histology.Dual phase helical CT scanMRIAngiographyArterial stimulation and venous sampling (ASVS) Sometimes tumor localization can only be achieved at laparotomy. Therapy of Metastatic Disease— Mets go to liver and axial skeleton.Somatostatin analogs —Octreotide can reduce gastrin levels, and may slow tumor growth; objective evidence of antitumor activity is rare . Its effect is unpredictableLanreotide is the alternative and can be used in a depot form Medical ManagementThe aim should be to reduce gastric acid secretion to < 10 meq/h prior to the next dose.Most places give 60mg/day of omeprazole.PPI doses can be reduced once control of gastric output has been achieved unless the patient has MEN1. Surgery TreatmentSurgery gives a 50% cure rate esp with extrapancreatic gastrinomas.Resection is not recommended if MEN1 as it wont be curative.Post resection gastric secretion may stay elevated due to a residual excess of gastric parietal cells due to chronically elevated gastrin levels.40 % need prolonged PPI. Main methods Other methods if still suspicious despite negative results Locali sation Treatment Liver-directed therapy Resection — Indication: For mets in absence of diffuse bilobar involvement, compromised liver function, or extensive extrahepatic metastasesNot curative, but prolongs life as slow growing tumoursHepatic artery embolization —Response rates > 50%RFA and cryoablation — Indication: Usually for smaller lesions and effects not predictableLiver transplantation — Only rarely done. Unknown if effectiveChemotherapy and novel treatment approaches — Streptozocin and doxorubicin. Radiologic response rate: 25%. Uncertainty as to efficacy, as well as the toxicity of this regimenAntitumor activity has also been shown for regimens containing the orally active alkylating agent temozolo-mide. Other approaches include radiotherapy, inhibitors of angiogenesis and small molecule tyrosine kinase inhibitors Patients with lymph node metastases had the same mortality as those who were free of visceral metastases. Patients with MEN 1 had a significantly lower rate of metastasis at the time of initial diagnosis (6%); their high overall survival rate (100% at 20 years) reflected this fact. Liver metastases were found in 24 % of patients at the time of diagnosis; the majority of these patients had a primary pancreatic neoplasm, and 67% had primary tumors that were greater than 3 cm in size. Patients with liver metastases had a 10-year survival of only 30%compared to a 15-year survival of 83% in those without liver metastases Posttreatment Surveillance3+6m post op— Serum gastrin, and CT/MRI. Long-term — Yearly tumour markers for 3 years. Zollinger Ellison Syndrome Treatment Written by Dr Sebastian Zeki

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