Content area
Full Text
KEY WORDS: gastrinoma; gastric surgery; hypergastrinemia; gastric hypersecretion; Zollinger-Ellison syndrome.
With the understanding of the role of H. pylori in causing peptic ulcer disease (PUD) and the development of potent gastric antisecretory drugs, the number of patients undergoing gastric acid-reducing surgery (vagotomy and drainage procedure, Billroth I and II resections) is decreasing rapidly (1). One of the welcome results of this decrease is that physicians see fewer patients with postgastrectomy problems. However, a negative aspect of this result is that they also are less familiar with treating such problems. Recurrent PUD after a Billroth II operation is uncommon (0.5-6%), but when it occurs it is a difficult management problem (1-3). It can be caused by an incomplete vagotomy, insufficient gastric resection, mechanical dysfunction of the stoma, the frequent use of aspirin or NSAIDS, incomplete excision of the gastric antrum from the detached duodenum (retained gastric antrum), or Zollinger-Ellison syndrome (ZES) (1-3).
Even when gastric acid-reducing surgery with Billroth II resection was a frequent operation in the United States, retained gastric antrum (RGA) was an uncommon cause of recurrent postoperative ulcer (1-3). In the past this diagnosis was frequently not considered, resulting in delays of diagnosis longer than 20 years (4-8). With the decreasing frequency of gastric acid-reducing surgery and the decreased exposure most physicians will have to patients with recurrent ulcers postoperatively, it is likely in the future this diagnosis will be missed for an even longer period of time. This is unfortunate because this condition can cause repetitive ulceration with recurrent bleeding; however, if diagnosed, it is completely curable by surgical resection of the retained antrum.
In this case report we describe a patient in whom the diagnosis of RGA was missed for 31 years and discuss techniques that are available that, if performed, will establish the diagnosis and lead to its cure.
CASE REPORT
Clinical History
A 58-year old white male was referred to the NIH with a possible diagnosis of ZES and was evaluated in September 1997. He had a seven-year history of recurrent abdominal pain and bleeding from anastomotic and jejunal ulcers. Thirty-one years prior to the evaluation (February 1966) he had undergone a partial gastrectomy with a gastrojejunostomy anastomosis (Billroth II reconstruction) without vagotomy after a three-year history...