Zollinger-Ellison syndrome differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]

Overview

Zollinger-Ellison syndrome must be differentiated from gastric antrum syndrome, antral G-cell hyperplasia, peptic ulcer, gastroesophageal reflux disease (GERD), and hypergastrinemia.

Differentiating Zollinger-Ellison syndrome from other Diseases

Zollinger-Ellison syndrome must be differentiated from diseases that cause abdominal pain and chronic diarrhea. The table below summarizes the findings that differentiate watery causes of chronic diarrhea:

Cause	Osmotic gap		History	Physical exam	Gold standard for diagnosis
	< 50 mOsm per kg	> 50 mOsm per kg*
Zollinger-Ellison syndrome	+	-	Abdominal pain and diarrhea Dyspepsia Upper or Lower gastrointestinal bleeding	Abdominal tenderness Hematochezia Hematemesis Tachycardia Hypotension	Gastrin levels
Crohn's disease	+	-	Abdominal pain followed by diarrhea	Abdominal tenderness when palpated in severe disease Blood seen on rectal exam Fever Tachycardia Hypotension	Colonoscopy with biopsy
Hyperthyroidism	+	-	Excessive sweating Heat intolerance Increased bowel movements	Lump in the neck Proptosis Tremors Increased DTR	TSH with T3 and T4
VIPoma	+	-	Watery diarrhea Dehydration (thirst, dry skin, dry mouth, tiredness, headaches, and dizziness) Lethargy, muscle weakness Nausea, vomiting Cramping abdominal pain Weight loss Flushing	Tachycardia Rash Facial flushing Abdominal distention Abdominal tenderness in the right upper abdominal quadrant	Elevated VIP levels Followed by imaging
Lactose intolerance	-	+	Abdominal pain Bloating Diarrhea Flatulence	Abdominal tenderness	Intestinal biopsy
Celiac disease	-	+	May be asymptomatic Vague abdominal pain Diarrhea Weight loss Malabsorption/steatorrhea Bloatedness	Abdominal pain and cramping Abdominal distention Tetany Mouth ulcers Dermatitis herpetiformis Signs of the fat-soluble vitamins A, D, E, and K deficiency	IgA tissue transglutaminase Ab
Irritable bowel syndrome	-	-	Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following: Improves with defecation Onset associated with change in frequency of stool Onset associated with change in appearance of stool 25% of bowel movements are loose stools History of straining is also common.	Abdominal tenderness Hard stool in the rectal vault	Clinical diagnosis ROME III criteria Pharmacologic studies based criteria

Zollinger-Ellison syndrome also must be differentiated from diseases that cause dyspepsia:

Disease name	Presentation	Cause	Differential diagnosis features
Zollinger-Ellison syndrome	Dyspepsia Recurrent peptic ulcers Chronic diarrhea	Increased gastrin secretion from tumor cells	High serum gastrin level Secretin stimulation test
Gastroesophageal reflux disease (GERD)	Dyspepsia	Lesser esophageal sphincter dilation	Normal gastrin levels
Peptic ulcer disease	Dyspepsia	Multifactorial	Ulcer in endoscopy
Antral G cell hyperplasia/hyperfunction	Dyspepsia	Increased G cell numbers	Poor response to secretin stimulation test No gastrinomas on imaging
Retained antrum syndrome	Recurrent peptic ulceration after gastrectomy	Incomplete excision of the gastric antrum from the duodenum	Modest hypergasterinemia when compare with gastrinoma Hypergastrinemia is reversible with excision of the retained antral remnant

References

Template:WH Template:WSRetained antrum syndrome