- Dx: Patients present with hypergastrinemia and severe recurrent peptic ulcer disease (Zollinger Ellison syndrome)
- Rule out MEN I (parathyroid, pancrease, and pituitary tumors).
- Fasting gastrin > 100 (> 500 is diagnostic).
- Secretin stimulation test confirms (gastrin increases with gastrinoma).
- Localization is done with CT, octreotide scan, IOUS, or duodenoscopy.
- Tx: Management depends on localization (gastrinoma triangle is junction of cystic duct, the common bile duct, and D2/D3 junction inferiorly)
- Duodenum gets enucleation (consider whipple if unable to enucleate)
- Metastasis to liver gets debulking, PPI, somatostatin, and streptozotocin.
- Non-localization gets duodenotomy, IOUS, consider acid reducing operation, and somatostatin.
- Dx: Patients present with Whipple's triad (hypoglycemia symptoms, hypoglycemia, and relief of symptoms with glucose).
- Elevated insulin, low glucose, elevated C-terminal peptide.
- Rule out MEN I
- Differential of hypoglycemia includes cirrhosis, glycogen storage disease, large tumors.
- Localization is done with CT ab/pelvis, octreotide scan, arteriogram, or IOUS.
- Tx: Start with diazoxide or somatostatin until surgery.
- Surgical treatment in enucleation
- If unable to localize, can do distal pancreatectomy and frozen section.
- MEN I should have subtotal pancreatectomy
- Dx: These are discovered incidentally on CT scan for other reasons
- Determine size and hounsfield units for likelyhood of malignancy.
- Adenoma is <4cm, <10 hounsfield, and fatty.
- Carcinoma is >4cm, have necrosis, calcifications, and hemorrhage.
- Start with biochemical evaluation:
- 24hr urine cortisol
- 24hr urine metanephrine, normetanephrine
- Aldosterone/renin if HTN and hypokalemic (Abnormal ratio is > 20)
- Tx: Managment depends on size and activity.
- Biochemical activity requires resection.
- Tumor < 4cm can watch
- Tumor > 4cm needs excision
- Laparoscopic adrenalectomy can be used for tumor < 6cm.
- Anterior Adrenalectomy:
- Laparotomy and survey abdomen.
- Left side= take down splenic flexure
- Right side= take down hepatic flexure, kocherize the duodenum, take down right triangular ligament.
- Enter gerota's fascia, start cephalad, and dissect towards renal hilum.
- Dissect between adrenal and pancreas/spleen (left) or liver (right).
- Identify adrenal vein and ligate (left side renal vein, right side off posterior surface of IVC).
- Continue dissection over renal capsule.
- Remove retroperitoneal fat with the adrenal gland.