Hypergastrinemia and recurrent type 1 gastric carcinoid in a young Indian male: Necessity for antrectomy?

Table 1 Differential diagnosis of hypergastrinemia

Elevated antral pH		Gastrinoma
Chronic atrophic gastritis-type A		++++ (> 1000)
Pernicious anemia	++++ (> 1000)
Other immune dz (RA, vitiligo, SS, DM)	+ (150-250)
Chronic atrophic gastritis-type B (H.Pylori), gastric cancer	++ (250-450)
Renal insufficiency/high protein diet	+ (150-250)
Massive small bowel resection	+ or ++
G cell hyperplasia/pyloric outlet obstruction	+ or ++
Calcium, caffeine, insulin, catecholamines	+ (150-250)
H2 blocker/PPI’s	+ (H2) ++ (PPI)
Truncal vagotomy/retained antrum s/p surgery	+

Gastrin level in pg/mL: + equals 150-250 pg/mL; ++ equals 250-450 pg/mL; +++ equals 450-1000 pg/mL; ++++ equals > 1000 pg/mL. dz: Diseases; RA: Rheumatoid arthritis; SS: Sjogren's syndrome; DM: Diabetes mellitus type 1; H2: Histamine H2 receptor blockers; PPI's: Proton pump inhibitors.

Table 2 Gastric carcinoid types and differentiating characteristics

	Type 1	Type 2	Type 3
% of gastric carcinoids	70%-80% - most common	Less than 5%	15%-20%
Association	Chronic atrophic gastritis	Gastrinomas (Zollinger-Ellison)	Sporadic carcinoid syndrome
Epidemiology	Typically women 50-70 yrs old	Family hx of MEN type 1 syndrome	Increased in African Americans
Presentation	Asymptomatic or anemia	Peptic ulcer disease	Hepatic mets or carcinoid syndrome
Rate of metastasis over a lifetime	< 2% even if larger than 2 mm	2%-4%	65% metastatic at presentation
Treatment	Observation vs endoscopic resection vs antrectomy	Endoscopic resection vs antrectomy vs octreotide vs gastrectomy	Partial or total gastrectomy with lymph node dissection vs chemotherapy

hx: History; MEN: Multiple endocrine neoplasia.