No abstract

A 61-year-old male patient, who had undergone surgery for a perforated small bowel ulcer two weeks earlier, reported for an outpatient visit to the gastroenterologist (TS). The patient presented with diarrhoea, weight loss, and weakness.He had suffered from watery diarrhoea, with 20 to 30 bowel movements daily, for five years. Despite having visited many different specialists, his problems remained unresolved. Common causes of diarrhoea were excluded, including bacterial infection, parasites, colorectal cancer, inflammatory bowel diseases, and celiac disease. Colonoscopy with biopsy (2×), computed tomography (CT) of the abdomen (1×), and ultrasonography of the abdomen (3×) were performed and revealed no abnormality. Meanwhile, the patient lost 30 kg and was so weak that he could not even walk. His medical history also included severe reflux oesophagitis and duodenal peptic ulcer, with good response to typical treatment 4 years before. His family history was unremarkable.Clinical examination revealed mild-severe general status, cachexia, paleness, and tachycardia (110 bpm). Standard laboratory tests showed mild anaemia, hypoproteinaemia, and dyselectrolitaemia. Results of other blood tests were within normal ranges.According to the clinical presentation, gastrinoma was suspected, and high doses of oral esomeprazole (160 mg daily) were administered. Rapid improvement of symptoms with cessation of diarrhoea was achieved. Gastroscopy revealed thickening of gastric folds (Fig. 1). Positron emission tomography (PET/CT) with [ 68 Ga] Ga-DOTATATE demonstrated a 10-mm soft tissue lesion with increased somatostatin receptor expression located close to the duodenum (Fig. 2). This lesion was visualized as an abnormal lymph node (12.5 mm) in the hepatoduodenal ligament during endoscopic ultrasound (Fig. 3). The patient also had a slightly increased level of gastrin (190 pg/mL; normal level 100 pg/mL).