Duodenal Bulb Mucosa with Hypertrophic Gastric Oxyntic Heterotopia in Patients with Zollinger Ellison Syndrome

Abstract

Objectives. Zollinger-Ellison Syndrome (ZES) results in hypersecretion of gastric acid (via gastrinoma) leading to peptic ulcers, diarrhea, and abdominal pain. We describe the novel discovery of hypertrophic, heterotopic gastric mucosa in the proximal duodenal bulb in patients with ZES, which we hypothesize results in an increased incidence of postbulbar ulcers in patients with ZES (a mechanism previously unreported). We determined the incidence of the novel finding of duodenal gastric oxyntic hypertrophic heterotopia (GOH) in patients with ZES. Methods. Seven patients with ZES were enrolled. The diagnosis of ZES was established by hypergastrinemia, gastric acid hypersecretion, and a positive secretin test or based on biopsy specimens (evaluated via tissue staining). Basal acid output (BAO) and baseline gastrin secretion were determined by established methods. Endoscopic examinations with methylene blue staining and biopsy of the gastric and duodenal mucosa were conducted in all patients every 3–6 months for an average of 5 years. Results. The duodenal mucosa demonstrated hypertrophic GOH in 5 out of 7 patients with ZES and an intact stomach and duodenum. Biopsies from the bowel mucosa demonstrated patchy replacement of surface epithelium by gastric-type epithelium with hypertrophic oxyntic glands in the lamina propria in 5 patients. Two of the patients had no evidence of GOH in the duodenal bulb. Patients with GOH had an average serum gastrin level of 1245 pg/mL and BAO of 2.92 mEq/hr versus 724 pg/mL and 0.8 mEq/hr in patients without GOH. Conclusions. This study demonstrated the presence of duodenal mucosa with GOH in 5 out of 7 patients with ZES and an intact stomach and duodenum. The presence of hypertrophic and heterotopic gastric mucosa is proposed to result from increased gastrin levels and may contribute to the increased incidence of postbulbar ulcers in these patients.

Hemorrhage from Extra-Antral Gastric Antral Vascular Ectasia in a Patient with Duodenal Heterotopic Gastric Mucosa

“…One study demonstrated that patients with gastric oxyntic heterotopia found in the duodenum had increased serum gastrin levels [16]. Our patient's duodenal mass histology indeed demonstrated oxyntic gastric glandular cells.…”

A Case of Heterotopic Gastric Tissue in Duodenal Bulb: An Interesting Endoscopic Finding

“…It can be found anywhere in the gastrointestinal (GI) tract [ 6 ]. GH in the duodenum is a benign condition and the incidence is reported to vary from 0.5 to 14%, although in the duodenal bulb, it is seen in only 0.5 to 2% of the general population [ 3 , 4 ]. Initial cases in the duodenum were identified on autopsies in a case series in 1927 [ 7 ].…”

“…It can be found throughout the gastrointestinal (GI) tract and usually occurs in the form of polyps, nodules, or tumorous growths [ 1 - 3 ]. In the duodenum, GH is most commonly seen in the duodenal bulb in the form of multiple polyps in approximately 0.5 to 2% of the general population [ 2 , 4 ]. It has characteristic endoscopic and pathologic findings that are often mistaken for gastric metaplasia [ 3 ].…”

Gastric Hypersecretory States: Investigation and Management

“…VIP) that would be normally present when the antrum is contiguous with the gastric body. 8 In addition, the isolated antrum is exposed to the neutral or alkaline environment of the duodenum thus promoting acid formation. The BAO and MAO are elevated as in ZES, although the increase in baseline serum gastrin is moderate in comparison (usually < 1000 pg/ml).…”

“…The BAO and MAO are elevated as in ZES, although the increase in baseline serum gastrin is moderate in comparison (usually < 1000 pg/ml). 8 99m Tc scanning is the imaging modality of choice when suspecting the diagnosis of retained antrum; management includes antral resection and vagotomy.…”