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Background
Gastrinomas are the most common type of pancreatic neuroendocrine tumours (PETs). 1 Most cases are sporadic; however, they can occur as part of multiple endocrine neoplasia-1 syndrome (MEN-1). 2-6 The most common symptoms of gastrinoma are abdominal pain and secretory diarrhoea. Peptic ulceration and severe esophagitis are not uncommon. 4 Sporadic gastrinomas usually occur in the gastrinoma triangle, which is linked embryonically to the ventral pancreatic bud. 1 7 8 Ectopic and extra-abdominal sites for gastrinomas have been described as well. 9-14 The existence of primary lymph node (LN) gastrinomas is questionable and controversial. 3 10 12 15-21 Determining whether they represent primary tumours or metastases from an occult primary site has been challenging. It remains a diagnosis of exclusion and has certain diagnostic criteria as well. 10 12 15 The proposed diagnostic criteria include rapid normalisation of the serum gastrin level after surgical excision of the tumour, absence of other primary tumours after careful surgical exploration, continuous normalisation of serum gastrin and absence of disease during the postoperative follow-up period. In conclusion, primary LN gastrinoma is uncommon but has been reported. Careful surgical exploration as well as postoperative follow-up are always warranted. 10 15 17
Case presentation
An African-American female aged 48 years presented with a history of recurrent acute on chronic pancreatitis, peptic ulcer disease with successfully eradicated Helicobacter pylori infection and recurrent Clostridium difficile infection. She presented to our institution with chronic abdominal pain and watery diarrhoea (15-20 episodes daily) that was severe enough to cause dehydration, acute kidney injury and electrolyte imbalance. On evaluation, she appeared to be dehydrated and distressed. An abdominal examination showed mild tenderness to palpation with no rebound tenderness, guarding or rigidity.
Investigations
Initial laboratory workup showed the following levels: Na 138mmol/L (normal: 136-144mmol/L), Cl 103mmol/L (normal: 95-105mmol/L), K 3.5mmol/L (normal: 3.6-5.1mmol/L), creatinine 3.6mg/dL (normal: 0.9-1.2mg/dL), lipase 23 units/L (normal: 13-60 units/L), haemoglobin 13.6g/dL (normal: 12-16g/dL) and white blood cells 13 600/cmm (normal: 4000-11000/cmm). She was admitted for the management of acute kidney injury, fluid and electrolyte replacement and symptomatic control.
A non-contrasted CT scan of the abdomen and pelvis did not show any acute abdominal processes. Tissue transglutaminase IgA was 1 unit/mL (normal: <4 units/mL). Her stool studies were negative for C. difficile. Additionally, her...