Multiple Duodenal Ulcers in a Patient Presenting with Epigastric Pain - Rare presentation in the Era of PPIs

This is the story of a 35-year-old otherwise well gentleman who presented with epigastric pain to our casualty surgical unit. He responded poorly to intial proton pump inhibitor therapy. Upper Gastro Intestinal Endoscopy showed multiple duodenal ulcers as seen in this video. He also had gastro eosophageal reflux disease. All these findings were suggestive of increased gastric acid secretion.

In the olden days gastric and duodenal ulcers were common as there was no effective medical treatment for hypergastrinemia until the discovery of Proton Pump Inhibitors (PPIs). Those days only effective treatment of this condition was to denervate the stomach by performing surgeries like highly selective vagotomy (Vegus nerve discharges parasympathetic signals to the stomach that increases its acid secretion). After Discovery of PPIs, incidents of gastric and duodenal ulcers reduced remarkably. Nowadays duodenal ulcers are very rare as PPIs are readily started in patients who are presenting with gastritis like symptoms.

So, discovering these duodenal ulcers were very surprising for us. It made us think about many possible causes for this condition in this patient including H. pyloric infections and Zollinger Ellison Syndrome.

During the endoscopy antral biopsies were taken for H. Pylori testing. Biopsies from duodenal ulcers are not required as duodenal ulcers are almost always benign and macroscopically all the ulcers looked benign.

Further assessment of the patient is planned as follows,

• Fasting serum gastrin levels and Gastric Ph studies. (Serum gastrin level more than 10 times the upper level of normal in the presense of gastric Ph below 2 is diagnostic of Zollinger Ellison Syndrome)
• Imaging to assess any pancreatic space occupying lesions that may be suggestive of Zollinger Ellison Syndrome.