Dear Dr. Roach: For more than three years, I lived with never-ending diarrhea. My doctor diagnosed me with irritable bowel syndrome. Once, I got very dehydrated and passed out after taking a shower. I was admitted to the hospital. An evaluation at that time, including a nuclear test, showed a tumour on my pancreas and another on my duodenum. My blood gastrin level was 600.
After the tumours were removed (they were benign), the level was 13. When I came home, I was free from diarrhea. Ever since then, I have had CT scans and blood tests, all fine. Has this happened to others?
C.D.
A gastrinoma is a tumour that produces the hormone gastrin, which has the physiological role of stimulating stomach acid secretion. These can be found in the pancreas or duodenum, and having multiple tumours is not uncommon.
Most people with gastrin-producing tumours (also called Zollinger-Ellison syndrome) have stomach ulcers due to the high amount of stomach acid. More than 90% have stomach pain. The high acid also prevents pancreatic enzymes from working and prevents the intestine from absorbing salt and water properly. This leads to diarrhea in 70% or so of people with this syndrome. The combination of diarrhea and abdominal pain can look like irritable bowel syndrome, especially in a person without ulcers, which is a big clue to this diagnosis. This is a rare disease, with one person per million diagnosed annually.
Although they may appear “benign” on pathology, they still have the potential to spread, so finding them early is best, and active surveillance is definitely indicated. Because gastrinomas are associated with other tumours as part of the “multiple endocrine neoplasia 1 syndrome,” a look for parathyroid tumours is appropriate as well.
It’s important to recognize that the diagnosis of irritable bowel syndrome is one of exclusion. This means that it is necessary to exclude other conditions before making the diagnosis. This does not mean everyone with IBS needs an evaluation for gastrinoma, though. Irritable bowel syndrome is present in 10-15% of the population, and very, very few of these are gastrinomas in disguise. Inflammatory bowel disease, however, is a much more common disease that masquerades as IBS, and new guidelines recommend a stool test to look for IBD, as well as testing for the parasite Giardia.
Dear Dr. Roach: I have osteoporosis and have developed a fractured T12 vertebrae. My middle toes are numb from pinched nerves. What’s my prognosis? What is the worst-case scenario?
V.W.
The vertebral column is a ladderlike stack of bones. Between the individual vertebrae is an important space for the spinal nerves to pass through. Pressure on those nerves can cause numbness, loss of reflexes, pain and weakness. The space can be lost by a herniated disk, which is an issue with the material that separates the vertebrae. Also, as in your case, a fracture can cause collapse of the vertebral body, just like a cardboard box gets crushed under too much weight on top.
The most common reason to treat these with a procedure is persistent pain. If you aren’t in pain now, your prognosis is good, although the toes are likely to stay numb.
The worst-case scenario is that you could have further osteoporotic fractures. Hopefully, you are already on appropriate treatment to reduce your risk of further fractures. Vertebral fractures can be very painful, and a hip fracture is a very dangerous problem, even more than vertebral fractures.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers can email questions to ToYourGoodHealth@med.cornell.edu
