S2939 A Not so Common Finding of Dyspepsia

Abstract

INTRODUCTION: Dyspepsia is a common symptom that around 20% of the population has one time or another developed. Of those who complain of this symptom, most do not seek medical care and of those that are referred for evaluation, 75% have no organic cause for their symptom. Of the most common findings, peptic ulcer disease, drug-induced dyspepsia or biliary source are a few causes of dyspepsia. However, less commonly gastric malignancy has been discovered as a potential cause as shown in this case. With the rise in incidence due to awareness and detection, suspicion should also be kept even with a nonspecific symptom of dyspepsia. CASE DESCRIPTION/METHODS: 51 year old female with obesity, hypertension and diabetes was evaluated for dyspepsia and reflux. The last year the patients symptoms have progressively worsened despite diet modifications and proton pump inhibitor twice daily. She denied any weight loss or abdominal pain, no dysphagia or intractable vomiting. She was referred for endoscopic evaluation as an outpatient. On EGD >10 nodules less than 1cm in size were discovered mostly in the body of the stomach. There was also a single, dominant mass 2.5 cm in diameter that was resected. Pathology returned as well-differentiated gastric neuroendocrine tumors with a low KI-67 labeling index <3% and immunostain for chromogranin was positive. Separate mucosal biopsies showed chronic active H. pylori gastritis and findings consistent of autoimmune/atrophic gastritis. Fasting gastric pH testing gave an esophageal pH of 6.9 and gastric pH of 6.5, helping to confirmed the diagnosis of type 1 gastric neuroendocrine tumor (NET). Labs showed an elevated gastrin level 2,288 pg/mL, vitamin B12 level 144 pg/mL and chromagranin A level of 1,141 ng/mL. Staging was done with a 68Ga-Dotatate PET/CT that showed focal uptake in the body of the stomach but no other uptake. Lastly, she was started on therapy with octreotide acetate LAR depot 20 mg monthly and intramuscular vitamin b12 injection. DISCUSSION: Gastric NETs has seen a steady rise of incidence as reported to NIH SEER program. With increased awareness, better detection rate during upper endoscopy and classification systems in place, better understanding and treatment modalities are available. Gastric NET is characterized by type 1, 2 and 3 and differentiated by tumor features, gastric pH and serum gastrin level among other things. From this it allows us to determine the risk of metastasis, 5-year survival and treatment modalities that are best suited for each disease.Figure 1.: Single nodule was noted in the antrum during upper endoscopy.Figure 2.: Retroflexed view of body of the stomach with several gastric nodules of multiple sizes. Loss of rugae folds in the body of stomach.Figure 3.: Solid, dominant mass large than 2 cm in the body of the stomach.