Recurrent Peptic Ulcer due to Carcinoid Tumour of Jejunum

Abstract

Carcinoid Tumours are classified as Neuroendocrine tumours. Commonly known ulcerogenic neuroendocrine tumour is Gastrinoma of the Pancreas and Duodenum.It secretes hormone Gastrin which causes hyperplasia of the gastric parietal cells with excessive secretion of hydrochloric acid resulting in multiple ulcerations in the stomach, duodenum and upper jejunum. Carcinoid tumours is not known to cause peptic ulceration. Keywords Peptic ulcer . Carcinoid tumour Case ReportA 17 year old male patient was admitted to the Department of Surgery in March 1997 with signs and symptoms of gastric outlet obstruction. In the preceding 2 years he was admitted to the same hospital 4 times with pain abdomen, vomiting, and malaena on 2 occasions. On each occasion upper G.I.Endoscopy showed ulcers in the stomach, 1st and 2nd part of Duodenum. He was treated conservatively with H2 antagonist, protein pump inhibitors, sucralfate with relief of symptoms. When presented with malaena and low haemoglobin blood transfusion was given.On admission he was haemodynamically stable. Routine blood tests including liver function tests, B.T, C.T, prothombin time and serum gastrin were done. Hb% was 9 Gm/dl and serum Gastrin 160 pg/L, twice the normal value. Rest of the tests were within normal limits. Upper G.I.Endoscopy and Barium studies confirmed gastric outlet obstruction and he was operated. As on earlier endoscopic examinations, this time also ulcers were found to extend up to 2nd part of Duodenum.On laparotomy, tail of pancreas had two tiny nodules and was removed. There were about a dozen fleshy enlarged lymph nodes in the mesentery, largest one about 3 cms. A hard nodule of about 1.5 cm was found on the anti-mesenteric border of the jejumun about 15 cm from the D-J flexure. The jejunal nodule and two enlarged lymph nodes were removed for histopathological examination. Truncal vagotomy and posterior gastrojejunostomy was done, utilizing the enterotomy in the jejunum created while removing the jejunal nodule. Rest of the abdomen including liver was normal. The patient had an uneventful recovery.Histopathological examinations of the Jejunal nodule showed picture of carcinoid tumour, mainly in the submucosa infiltrating the muscle and ulcerating the mucosa at one site only. Lymph nodes showed metastatic deposits; no pathology was found in the resected tail of the pancreas . Urinary 5HIAA was within normal limits.MEN Syndrome I was excluded from a normal skull X-ray.He was put on oral PPI and remained symptom free. He experienced occasional mild reflux symptoms well controlled by added antacid preparations. Check upper G.I. Endoscopy after 2 and 4 months showed complete healing of ulcers and healthy G-J stoma and PPI was stopped. He remained asymptomatic on regular follow up.After 11 months USG of abdomen showed doubtful lymphadenopathy. CT confirmed retroperitoneal lymphadenopathy and a doubtful jejunal mass. Second laparotomy was carried out in February,1998. Appendix was removed and multiple biopsies taken from thickened jejunal wall,