S2948 Chronic Intestinal Pseudo-Obstruction: A Rare Entity Related to Gastrinoma

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Introduction: Gastrinomas are one of several types of neuroendocrine tumors in the gastrointestinal (GI) tract. We report an unusual case of a patient with a gastrinoma, initially presenting with symptoms of global GI dysmotility. Case Description/Methods: This is a 63-year-old male who presented with abdominal pain, nausea, vomiting, and melena. His hemoglobin level was 7.7 g/dL. Upper endoscopy was performed revealing a 13 mm ulcer with pigmented spot in the duodenal bulb. The stomach mucosa was noted to be thickened in the cardia and body, and difficulty with insufflation was noted. Gastric biopsies showed chronic active gastritis with negative helicobacter stain. His hospitalization was prolonged due to intestinal distension which improved after nasogastric tube decompression. He had 3 additional hospital admissions for abdominal pain and distension, each of which improved after nasogastric and colonic decompression. During his fourth admission, he experienced brisk upper GI bleeding. An urgent upper endoscopy showed a 2 cm bleeding ulcer in the duodenal bulb, several clean-based ulcers in the gastric antrum and duodenal bulb, and two 7-8 mm nodules in the duodenal bulb. Although he was already on a proton pump inhibitor treatment for peptic ulcer disease, a gastrin level was checked and was 158 pg/mL. A copper CU-64 dotatate scan revealed a 0.5 x 1.8 cm soft tissue density with an increase-uptake adjacent to the pancreatic head and enlarged aortocaval and portal hepatis lymph nodes. A subsequent endoscopic ultrasound showed no discrete mass at the head of pancreas. Tissue was obtained from enlarged lymph nodes and from nodules in the duodenal bulb. Pathology revealed a well-differentiated WHO grade 2 neuroendocrine tumor. He underwent a Whipple procedure, and gross pathology confirmed metastatic gastrinoma to regional lymph nodes. Discussion: Common manifestations of gastrinomas include peptic ulcer disease, diarrhea, weight loss, and heartburn. About 1-10% of gastrinomas can be part of multiple endocrine neoplasia type 1 and can have hormonal symptoms related to the syndrome. However, GI dysmotility without mechanical obstruction, known as chronic intestinal pseudo-obstruction (CIPO), together with gastrinoma, is rare. To the best of our knowledge, only cases of bronchial neuroendocrine tumors and CIPO have previously been described. Treatment of the neuroendocrine tumor results in improvement and resolution of CIPO.Figure 1.: A Picture demonstrates a bleeding duodenal ulcer (on the left) and thickened gastric fold on retroflexion view (on the right).

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