Journal of Clinical Cases

Primary Gastro Hepatic Recess Gastrinoma: A Rare Extra Pancreatic And Extra Intestinal Location Of Gastrinoma.

Dr. Sayed Moosa Kazim¹ , Dr. Zulqarnain Hyidar² , Dr. Fatima Tu Zahara¹ , Dr. Zain Tayyab ¹ , Dr. Muhammad Awais¹ , Dr. Aamir Ali Syed¹

1. Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan.
2. Shalamar Institute of Health Sciences Lahore, Pakistan.

Corresponding Author: Fatima Tu Zahara, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan.

ABSTRACT

Introduction: Gastrinomas are rare neuroendocrine tumors that are typically located within the gastrinoma/Zollinger-Ellison Syndrome (ZES) triangle. However, rare cases have been reported in locations such as the body of the stomach, jejunum, peripancreatic lymph nodes, splenic hilum, omentum, liver, gallbladder, common bile duct, and ovary. The average reported size of a gastrinoma is generally less than 4 cm. Gastrinomas in the gastrohepatic recess are extremely rare, with no cases reported to date. We present a case of a gastrinoma originating from an ectopic site with an unusually large size.
Case Report: A 23-year-old male trainee athlete presented with reflux symptoms, vomiting, loose stools, and altered bowel habits for the past 18 years. He had been regularly taking proton pump inhibitors (PPIs) for over 10 years. He had also undergone exploratory laparotomy 7 years ago for a perforated gastric ulcer, though the operative record was unavailable. Initial abdominal ultrasound revealed an epigastric mass, which was further investigated with CT and MRI scans. These imaging studies showed a multilobulated, heterogeneously enhancing mass with central necrosis and multiple calcific foci in the upper abdomen, located in the gastrohepatic recess. The scans also identified multiple variable-sized simple hepatic cysts. An ultrasound-guided core biopsy of the lesion confirmed a Grade I neuroendocrine tumor. Based on this, the patient’s serum gastrin levels were found to be >1800 pg/ml (more than 10 times the normal value). The case was discussed in a multidisciplinary team (MDT) meeting, and surgery was recommended. The patient underwent surgical excision of the gastrohepatic recess mass, measuring 10 x 6 cm. No distant metastasis was observed during the surgery. The final histopathology confirmed a Grade I neuroendocrine tumor. Post-surgery, the patient’s serum gastrin levels dropped to 189 pg/ml immediately and 79 pg/ml five days after surgery.
Conclusion: In this case, the gastrinoma was located in an extremely rare site, and the mass was unusually large. The mainstay treatment of any well localized/non metastatic gastrinoma is surgical resection like in our case, irrespective of size and rare location.

Keywords: GaStrinoma, ZES, Surgical resection, Gastrin, Gastrohepatic recess, ectopic location..