A 45 year old gentleman has undergone truncal vagatomy and pyloroplasty for bleeding duodenal ulcer seven years ago. Now he was intractable recurrent symptoms of peptic ulcer. All of the following suggest the diagnosis of Zolliner Ellison syndrome, except

Gastrinoma (Zollinger-Ellison syndrome) Zollinger-Ellison syndrome (ZES) is a condition that includes: (1) fulminating ulcer diathesis in the stomach, duodenum or atypical sites; (2) recurrent ulceration despite 'adequate' therapy; and (3) non-beta islet cell tumours of the pancreas (gastrinoma). Pathology The aetiology and pathogenesis of sporadic gastrinomas are unknown. At the time of diagnosis more than 60% of tumours are malignant. Pancreatic gastrinomas are mainly found in sporadic disease; most are found in the head of the pancreas. More than 70% of the gastrinomas in MEN 1 syndrome and most sporadic gastrinomas are located in the first and second pa of the duodenum. Therefore, the anatomical area comprising the head of the pancreas, the superior and descending poion of the duodenum and the relevant lymph nodes has been called the 'gastrinoma triangle' because it harbours the vast majority of these tumours. All patients with gastrinomas should be tested for MEN 1 syndrome. Clinical and biochemical features Over 90% of patients with gastrinomas have peptic ulcer disease, often multiple or in unusual sites. Diarrhoea is another common symptom, caused by the large volume of gastric acid secretion. Abdominal pain from either peptic ulcer disease or gastro-oesophageal reflux disease (GORD) remains the most common symptom, occurring in more than 75% of patients. Biochemical diagnosis If the patient presents with a gastric pH below 2.5 and a serum gastrin concentration above 1000pg/mL (normal <100pg/mL) then the diagnosis of ZES is confirmed. Unfounately, the majority of patients have serum gastrin concentrations between 100 and 500 pg/mL and in these patients a secretin test should be performed. The secretin test is considered positive if an increase in serum gastrin of >200pg/mL over the pretreatment value is obtained; this also rules out other causes of hypergastrinaemia (e.g. atrophic gastritis). Ref: Bailey and love 27th edition Pgno : 851