A 50-Year-Old Man with Postprandial Epigastric Pain

Excerpt

A 50-year-old otherwise healthy man, with moderate hypertension, had suffered from intermittent postprandial epigastric pain and bloating for over 3 years. The pain was moderate in intensity, lasted for about 1 h, did not radiate, and had no obvious other precipitating or relieving factors. Although occasional belching was noted, the pain was not accompanied by nausea, vomiting, weight loss, or disturbance of bowel habits. Physical examination revealed an obese man with normal vital signs. His abdomen was soft, non-tender, and non-distended, and bowel sounds were normal. There were no masses palpable in the abdomen. Results of routine blood tests, including serum liver enzymes, bilirubin, amylase, and lipase, carcinoembryonic antigen and CA19-9, were all normal. Solid gastric emptying, delayed 36 % at 2 h, was initially treated empirically with domperidone 10 mg postoperatively three times a day, with partial relief of symptoms. A 0.5-cm duodenal bulb carcinoid was removed via endoscopic mucosal resection, with considerable improvement in his symptoms. Nevertheless, 2 years later during routine follow-up, an elevated serum concentration of chromogranin A, without elevation of concentration of any other gut hormone, was noted as part of an investigation for symptomatic relapse. A computerized tomographic (CT) scan of his abdomen and pelvis was unremarkable. He was then referred to an endoscopic ultrasound examination to evaluate the possibility of having residual or recurrent carcinoid tumor. Radial endosonography (EUS), although revealing no evidence of residual tumor, identified circumferential pancreatic tissue around the second portion of the duodenum, immediately distal to the duodenal sweep, with associated luminal narrowing (Figs. 1, 2). A magnetic resonance imaging (MRI) scan, with MR cholangiopancreatography (MRCP), confirmed the existence of an annular pancreas (Fig. 3a, b). A subsequent upper gastrointestinal barium study displayed narrowing of the second portion of the duodenum, but failed to reveal the presence of a dilated duodenal bulb, characteristic of the condition.

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